Eating disorders have long been known as one of the most challenging mental illnesses to treat. This article is divided into three categories based on what/ who causes the treatment challenges of eating disorders:
Unfortunately, since therapists and clients are humans, it is very difficult for both of them to deal with each other while eliminating any predisposed negative perceptions and similarly, the disorder has some elements that can change the type of treatment plan the therapist chooses for the client. Having one of these challenges solely does not act as a threat to the treatment plan. However, when all these three aspects are combined they pose serious obstruction to the success of implementing a plan, if the right plan, at all.
One of the major factors that impede the treatment process is how the therapist perceives the client. In fact, many therapists have negative predisposed attitudes about clients who suffer from eating disorders and this influences how successfully the treatment plan may be fulfilled. Here is where the social psychology theory called Self-fulfilling prophecy comes in practice. This theory claims that when people (therapists) have a certain expectation about what other people are like; these expectations influence how they (therapists) act towards the other person (client). This leads the other person (client) to behave consistently with people’s (therapists) original expectations, making them come true (Aronson et al., 2013). Analyzing the latter from a scientific perspective, researchers have found that there are three main components in a therapist-client interaction that can influence the treatment of any mental illness in general. These components are “working alliance, transference configuration and real relationship” (Gelso & Carter, 1994). Work alliance is a term used to describe the therapists’ efforts in aligning with the client’s ego and not being defensive while transference configuration is similar term to self-fulfilling prophecy. It is the possibility that clients will transfer feelings associated with bad experience to the therapist, have a set of expectations about their therapists and behave in ways that would provoke the expected response from the therapist. The therapist’s job is the “counter-transference”. In other words, prove the clients wrong and making them feel comfortable by showing them that their initial expectation were not true. The third component that scholars defined as “real relationship” has two important features that define the path of treatment especially of difficult mental illnesses such as eating disorders; “genuineness and realistic perceptions”. Being genuine defines being trustworthy, open, honest and faithful as a therapist and the realistic perceptions refers to the therapist and the client perceiving each other accurately and not from their own expectations (Gelso & Carter, 1994). However, these three components describe the perfect therapist-client relationship for a successful treatment but what happens in reality almost goes against all the three components.
For many years I resisted treating anorexics. These girls frightened me, and I was frightened for them. Working with them was grueling, unrelenting and often frustrating. It was almost impossible to leave work at work. I would find myself worrying obsessively about one client or another, fearful that they were going to die and/or I would be sued for malpractice. These were clients who did not want to be there, in your office, working with you, and they utilized enormous denial and resistance equal to that of alcoholics. It was often difficult to form therapeutic alliance, and rarely did I receive anytime of “strokes” or reinforcements, as I did with other clients. They often lied to me or cheated –one client put pennies in her panties, another wore a weight belt and many tried drinking copious amounts of water prior to sessions to “make weight.” Every time I started thinking I knew all of the tricks of the trade, I would find out I had been deceived.” – said W. White, M. White (2000, p. 221)
Unfortunately, some of the expectations that therapists have about clients with eating disorders overlap with the anecdote above. Therapists believe that individuals with anorexia and bulimia to be “manipulative, self-absorbed, selfish, irrational and self-destructive.” (Geller et al., 2001). Moreover, the way therapists perceive these traits of individuals who have eating disorders influence the treatment path that they choose for their clients. W. White and M. White (2000) conclude that a therapist can view these traits as “a pathology or pitfalls”. Moreover, Psychologist Sills has identified a number of problem behaviors in anorexia and bulimia clients that include loss of control, hyper sensitivity, emotional over dependence and unrealism. If a therapist considers these descriptions as a pathology, s/he would probably create a different treatment plan than if they deal with these descriptions as pitfalls in personality such as “learned helplessness” that can be treated by a different plan, through the behavioral model for instance (Lavender et al., 2013).
Eating disorder factors:
First of all, anorexia nervosa, bulimia nervosa and binge-eating are different eating disorders based on the DSM-5 but in reality this is not always the case. Sometimes clients have symptoms that overlap with more than one eating disorder, making the distinction invalid. In fact, the DSM-5 gives “the diagnosis of anorexia nervosa to people with features of bulimia nervosa at low weight.” (Palmer, 2005). However, it is worth noting that the inclusion of binge-eating syndrome as a district eating disorder in the DSM-5 has clarified that there were many clients misdiagnosed as having anorexia or bulimia (based on their size) because of the fact that they binge, ignoring the fact they do not purge (Psychatry.org, 2013).
Moreover, a term that psychiatrists have created for those patients who have symptoms that overlap with anorexia and bulimia is bulimarexics. In fact, “fully 50 percent of anorexics have episodes of binge-eating, while bulimarexics purge via long periods of starvation and/or excessive exercise, and as many as 50% of bulimarexics may have long history suggestive of anorexia.” (W. White & M. White, 2000) Hence, the two disorders should be viewed as “two ends of a range of possible consequences of extreme concern about weight and shape and consequent dietary restraint.” (Palmer, 2005) Plus, The DSM-IV has defined a wide range of symptoms that do not necessarily fulfill the diagnostic criteria for Anorexia and Bulimia. Some of which have been eliminated from the DSM-5, for example amenorrhea which is absence of the menstrual cycle was one of the side effects of starvation in anorexia nervosa. (Palmer, 2005)
Second, there is a high comorbidity rate between eating disorders and other disorders “that include both Axis I (current psychiatric disorders) and Axis II (longstanding personality disorder, as described in the DSM-IV-TR.” (Cooper & Todd, 2009). On the left are the possible disorders that can co-occur with eating disorders (Cooper & Todd, 2009). This comorbidity raises the question as to which disorder took place first. In fact, “almost 50% of people with eating disorders meet the criteria for depression” (ANAD, 2014). What therapists do most of the time is draw a correlation effect between two or more disorders rather than assume that one had caused the other because it is almost impossible to guarantee that the latter assumption is correct. In fact, having more than one disorder probably means there will be more than one treatment plan or style to adapt to the needs of the client and sometimes it is hard to treat both disorders parallel to one another. Moreover, there could be a third trigger that led to both disorders. For example being exposed to early childhood trauma can induce bulimia nervosa and at the same time a stress disorder. In fact, psychologists have concluded based on studies that “there is a link between core beliefs (defectiveness and shame), early childhood experiences and bulimic symptoms” (Cooper & Todd, 2009, p.61). In other words, there are many factors that contribute to the disorder, directly or indirectly. Despite the presence of Gestalt therapy, where therapists deal with the disorder as a whole, taking into consideration the treatment of other comorbid mental illnesses, cultural, societal and familial factors that contribute to the illness, many therapists don’t use it. It is very difficult for one therapist to handle all these factors at the same time. Therefore, many therapists do not consider it or contemplate it along with other therapists to treat one client. However, these therapists should have a good relationship and reach an agreement because their behavior will be reflected in therapy sessions and will influence how efficiently the client responds to treatment (Gelso & Carter, 1994).
Plus, it is important to keep in mind that many patients with eating disorder do not consider going to a therapist except when their case is already severe which explains why, in Japan, out of 117 eating disorder patients 100 of them needed immediate hospital admission and especially those who had restrictive type anorexia nervosa were those who needed to be treated as inpatient and did not improve as outpatient (Nakadoi et al., 2011). Unfortunately, many of the hospitals or therapy centers do not have enough space to keep all their eating disorder clients who need serious help. For example in “Germany alone, ten extra sites were needed for recruitment of 242 patients” (Bulik, 2014). Another major problem that patients face is how expensive a therapy session is. It is true that there are many insurance companies that can cover a certain percentage of the session fees but many companies do not provide this deduction till the treatment period is over. Moreover, even the percentage that the insurance covers is not good enough because the left percentage that the patient needs to pay is still a large amount. This is why many clients prefer not to go for therapy in the first place because they do not have the financial capabilities.
Unfortunately, many eating disorder clients especially inpatients experience a relapse after treatment. One possible reason is that most of the time they do not finish the treatment course until they are fully treated. When they are half way in their treatment, they assume that they are already cured and stop the therapy. Another reason that influences relapse rates is the type of treatment that clients receive. As mentioned earlier many of the clients leave themselves till the very last minute before they decide to go to a therapist and therefore they need immediate care and could possibly become inpatients. However, despite the fact that the client will get the care they need as an inpatient, there are draw backs to this type of treatment. The draw backs are similar to having the client in the therapy session away from their social contexts or from their family and friends. Being deprived from their social context during treatment can possibly be eliminating a causing factor to the disorder which will help the client get treated easier and faster. However, this will sadly increase relapse chance once the patient is put back in his/ her original environment especially if it is what triggered the disorder.
The nature of eating disorder has a component of obsessions and compulsions to it. Those who suffer from eating disorders have compensatory behaviors that make the disorder more like a vicious cycle that is a challenge for the therapist to cut through. For example in anorexia, patients punish themselves when they eat more than a certain amount of calories by hurting themselves and similarly, those who are bulimic practice self -induced vomiting. Using laxatives and diuretics to control weight is also part of the vicious cycle and the challenge in treatment here is that the body (chemically and psychologically) gets used to a certain habit that the client practices (W. White, M. White, 2000).
Another issue that challenges the treatment plan for eating disorders is the deformed perceptions that patients have about themselves. Whether in bulimia, anorexia or binge-eating disorder, the client has negative cognitions about themselves. In binge-purge disorder, clients believe they are out of control especially in the binging sessions. They feel they are not good enough when they realize they ate a lot of calories and that these calories will influence their size because being thin is never good enough. In other words, they feel insecure because they don’t fit in. This leads them to believe that even psychotherapy will not help because the problem is within themselves and that they are never good enough. During binging sessions, they even hide so that nobody would see them committing that embarrassing sin from their point of view which makes the client feel that they are hypocrites. Similarly, anorexics and bulimics face similar deformed cognitions however, they are more determined and fixated that they don’t want to get out of the cycle of being skinny. These clients mostly fear that the therapist will make them gain weight with the treatment and they are very worried about how the therapist would perceive their compensatory behaviors. Eating disorder clients believe blindly that “it is impossible to overcome” their illness (Cooper & Todd, 2009).
In addition, even when clients accept treatment, they either “miss appointments or leave out crucial details in their story” and this affects the therapists’ evaluation of the problem (Cooper & Todd, 2009). Another problem is that the treatment plan takes a really long time of approximately 10 months to give any positive results. This increases the dropout rates and acts as an obstacle to implementing the treatment plan. In fact, in anorexia nervosa alone, control studies have revealed dropout rates that have increased from 15.3 percent to 24.4 percent in the year 2013 (Bulik, 2014).
To conclude, eating disorders are one of the most challenging mental illnesses to treat. This paper has divided these treatment challenges into three categories based on whether they are therapist based, eating disorder based or client based. Both clients and therapists most of the time have deformed perceptions about the client. Plus, problems with the diagnostic criteria and DSM-5 manual makes it easier to diagnose clients if therapists view eating disorders as illnesses along the same continuum rather that distinct disorders. The nature of how expensive psychotherapy is prevents many clients to go for therapy especially eating disorder clients since the illness takes a long period to recover. Many patients with draw from the treatment or skip sessions because they fail to see any improvement within a short time frame.
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