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Resistance to Treatment

It is very common, indeed it is one of the hallmarks of the illness, that patients resist treatment for eating disorders.. Parents and family members often find themselves arguing with the patient trying to convince him or her of the seriousness or the facts of the illness.
 

 

Types of Resistance

Families should be aware that resistance to treatment can come in many forms including concealing symptoms, hiding food, faking weights, self-harm, verbal and physical attacks on care givers, false or distorted stories to authorities, threats of suicide and self harm, actual suicide and self-harm. While friends and families see an illness causing damage and pain often the patient remains convinced the situation is under control. Patients often hide symptoms and trick family and even doctors into believing things are better than they are.

Waiting for "Insight?"

Regardless of age, families should not delay treatment while waiting for insight or motivation, or settle for treatment that only addresses insight and motivation without also including medical treatment and restoration. Whether the patient is able to understand or not, the family can do everything possible to facilitate treatment. In other words, the level of resistance ought not guide treatment decisions.

Anosognosia

It is very important that families know that eating disorder patients are often "anosognosic." They are blocked in their own minds from seeing the gravity of the illness or the risk of the behaviors. This is especially frustrating when the patient is able to maintain other parts of life, like work and athletics and academics, at a high level at the same time believing one can ingest calories from smells or that food is unnecessary.

This is a condition similar to that found in certain brain injuries, and is reversible. However, with full nutrition and normalized eating and behaviors the patient can regain self-awareness and engage in therapy and learning that then can nurture insight and motivation.

More on Anosognosia from the Treatment Advocacy Center...

Dealing with Resistance

Keeping patients and other family members safe while refusing to enable eating disorder behavior is the highest priority during eating disorder recovery. Patients and siblings need to know that the anxiety and resistance of the patient will neither delay care nor will it be allowed to harm anyone.

As difficult as recovery is, delayed recovery is harder. Although early intervention and firm boundaries in the home can be enough to contain resistance it may also be necessary to use inpatient care when situations arise that the family cannot handle safely at home. The time a patient is hospitalized is an opportunity for the family to create safe boundaries for after discharge.

Separating the Illness from the Patient

"Some patients lash outward during the necessary anguish of recovery, some suffer invisibly, but the pain is there. When parents and care givers react with anger, or with avoidance, we can inadvertently aid the illness. Our confident, optimistic, firm support is so important in helping our children feel safe." Laura Collins, F.E.A.S.T. Founder.

One tool for families to use when trying to understand eating disorders is to "separate the illness from the patient." This concept has many names, including "narrative" therapy and "externalization," and can be very helpful to caregivers. By seeing the actions and reactions of the patient as belonging to "ED" or "the illness," the parent can be freed from anger at the loved one and ally with the patient being held hostage and out of sight by this malignant condition.

Anger, frustration, bargaining, arguing, moral pressure, fear: all of these may be set aside when a parent knows they are not dealing with the loved one directly, but through the illness. The love a parent feels, as well as the optimism, need not be dependent on a loving or insightful response. By not taking the resistance, anger, and desperation of the patient personally, a caregiver is also free to make decisions based on the patient's needs and not his or her words.

Research & Resource Links

Treatment of Anorexia Nervosa against the Patient’s Will: Ethical Considerations,

by Tomas J. Silber, MD. Reproduced by permission of the American Academy of Pediatrics: Silber TJ. Treatment of anorexia nervosa against the patient's will: ethical considerations. Adolesc Med State Art Rev. 2011;22(2):283-8, x. "The central issue surrounding involuntary treatment is not whether the patient lacks the capacity to consent or refuse treatment but rather the context and relationships involved in quality care. At the end it is always values that underlie and strengthen the good work. These include fundamental respect for the person, even as liberty is restricted; beneficence; and truth telling."


Perceived Coercion and Change in Perceived Need for Admission in Patients Hospitalized for Eating Disorders

Conclusions: "Nearly half of patients with eating disorders who denied a need for treatment on admission converted to acknowledging that they needed to be admitted within 2 weeks of hospitalization."


Anosognosia Keeps Patients From Realizing They’re Ill

Psychiatric News 2001


A Neural Signature of Anorexia Nervosa in the Ventral Striatal Reward System,

October, 2009, "findings are consistent with predictions in animal studies of the pivotal role of the human reward system in anorexia nervosa and thus support theories of starvation dependence in maintenance of the disorder."

 



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