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The Need for Complex Ideas in Anorexia Nervosa: Why Biology, Environment, and Psyche All Matter, Why Therapists Make Mistakes, and Why Clinical Benchmarks Are Needed for Managing Weight Correction

Michael Strober, PhD, ABPP1, 2* Craig Johnson, PhD3, 4

Concluding Words and a Postscript on Consultation

We have presented an argument for understanding the mystery and danger of AN in the broadest context possible. In doing so, we have highlighted lessons being taught by numerous credible studies about biology, development, and life experience – lessons germane to psychopathology and to its treatment. We made the point that genes and biology are the fundamentally important starting point for understanding, because compulsiveness of habit, anxiety, low reward seeking, and behavioral regimentation are heritable phenotypes that ‘power’ the illness and sustain its self-rewarding properties. But equally important to this understanding is that these traits can be ‘opportunistically exploited’ by the psyche of AN to sustain its adaptive, self-rewarding effects. Whether we think the transformative process is unconscious or volitional is beside the point since the dividing line is too faintly drawn to determine where one ends and the other begins. Still, even though vulnerability begins with genes and biology, to assume there is neither intentionality nor volition involved at any level of the illness is a fallacy; biology and willfulness are not mutually exclusive processes. So what isn’t beside the point is that genes and biology should be viewed in functional terms, that the clinical implications of this viewpoint are many, and that molecular neuroscience reminds us that life experiences play a role in illness because even irrational mental states adapt to social pressures in a causal chain that shapes the course of development over many years. This is why throughout the article we stressed that a narrow conceptual vision of AN can never suffice as clinical theory because making pragmatic interventions the centerpiece of therapy is not only too deliberate, it is insufficiently sensitive to the contextual factors that can either promote or arrest symptom progression.

So coming to the end, we return to the touchy question of where things go wrong and why. Also, why is it that in preparing to treat a psychiatric illness we unhesitatingly agree is more complex and potentially threatening to health than any other, therapists rarely begin with a detailed, comprehensive, authoritative empirical and clinical account that establishes: what, exactly, is being treated; how the illness evolves and what processes underlie its self-perpetuating character; why the treatment is likely to be challenging and in what ways; how long a period of care may be needed, the elements of that care, and what risks result if the treatment should end prematurely; what benchmarks need to be followed to decide when more intense intervention is essential, and why; what behavioral, psychological, and life style changes signal that the end of treatment is at hand; and what personal, parent, family, and social strains may be important to consider, and to address therapeutically? Why does this rarely occur? We believe the reasons are several: 1. insufficient clinical experience; lack of breadth in academic and clinical training; and little exposure to other areas of psychopathology relevant to eating disorders;

2. a commitment to doctrinaire ideas and quickness to write off alternative possibilities for care;

3. lack of training and experience in combined clinical and academic settings that offer comprehensive, multidisciplinary, and higher levels of care, and a misguided disdain for hospital-based treatment.

How to put into words unfamiliar to either patient or family the many reasons why weight gain has become a fear so paralyzing it is resisted at all costs, and how to give far ranging explanations of what gives rise to the illness and the absurdly wild beliefs that become attached to its symptoms, are questions that underscore the essential wisdom of making far ranging clinical skills and diverse theoretical knowledge our foundation. Not only does it allow for answers to the questions patients and families surely have, it also articulates the unspoken resistances to change and the withering emotional highs and lows that may soon erupt for which everyone, therapist too, must prepare. This, in our experience, is the dialogue that has proved the most robustly effective means of helping parents (and other loved) separate illness from the person who bears the affliction; any other preparation is sterile and incomplete.

Who doesn’t wish for a treatment that can alleviate suffering quickly? But to think there is a decisive way of accomplishing it is risky and naive. Teaching parents skills to assist with weight gain is a good thing; we should do it. What is not a good thing is failing to recognize it must coincide with a seasoned ability to infer when the conditions for its success may not be present and how other interventions can assist. We know from colleagues, many interactions with therapists, and quite extensive experience with patients and families, that in the torrent of excitement that greeted FBT, it, and it alone, has assumed center stage in the care being delivered by many practitioners and many treatment centers whose knowledge of the illness is marginal. We understand this; when treatment service options are limited, a pragmatic solution is needed, and quickly. Still, it shouldn’t overshadow the need for platforms of teaching and skill building that are more comprehensive. And let us not forget another basic truth about people who struggle and the loved ones who understand little of how to help. Ultimately, it is the therapist’s knowledge of the mysteries involved and the wisdom they display in rendering their clinical judgments that instills hope and builds faith that what is being done follows a rationale that must be honored. Without this, the bond that tethers our patient to our treatment is a fragile one.