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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

The Impetus for This Clinical Perspective

It arose from a heated conversation that took place over dinner at a recent national meeting of eating disorder professionals. Present were the authors, several practitioners, and the founding member of a parent advocacy group with ties to the Academy for Eating Disorders (AED). The conversation eventually fixed on a question that was of particular concern to this parent, ironically enough harkening back to the lament of 19th century pioneers—William Gull and Ernest-Charles Lasegue—that both practitioner and family often went too far in indulging the patient’s wish to manage eating on their own. Listening to this parent’s account of her daughter’s treatment by a ‘‘specialist’’ she initially assumed trustworthy, it was clear how the treatment went awry and why her anger was deserved. ‘Why do therapists wait too long before realizing their patient can not gain weight?’ was the question she put to us.

Unfortunately, therapist complacency in addressing malnutrition remains, giving credence to this parent’s belief that clear thinking about how to approach AN’s intransigence is still lacking. So as the conversation came to a close our dinner companion suggested, with further encouragement from others at the table, that the authors—friends and colleagues for nearly four decades—write a commentary on this issue and that it be accompanied by a proposal: that outpatient management follow definable benchmarks for determining when a therapist should stop doing what has not been helpful and replace it with something that might be; specifically, a level of care offering greater support for weight gain and reduction of psychopathology. We acknowledged this was a worthy suggestion because as far as we know, little has been written about specific, treatment-focused benchmarks in AN.

But as we began to write, we felt that a discussion focused on benchmarks alone would not suffice because while they can be plausibly described, implementing them at a point in treatment when symptoms are worsening or progress has stalled is a unique challenge; and as our key point argues, not many challenges in AN can be managed without convincing insights and strong clinical skills. We wanted our younger colleagues to understand this; it became an important part of the reason we are writing this article.