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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

Our Framework

Modeling treatment on advances in our understanding of pathological processes in AN has long proven difficult; this is why controversy can be a good thing. But the sort of debate we need is not possible if arguments depend on fixed beliefs that are at odds with the very research cited in their defense, and if new treatment ideas are greeted either with gushing enthusiasm or disdain, rather than caution and humility. To be clear, we are focusing on the BBMI and FBT paradigms not because we disagree with them—there is good empirical support for the original concepts—but because a larger body of research shows that the interpretation of each needs softening, and because many have come to see the BBMI paradigm as justifying a therapy philosophy we believe is not only unwarranted, but contrary to good clinical care. What we mean here is that an increasingly genocentric view of AN is being overinterpreted to mean that weight correction is an absolute biological prerequisite for any treatment that is more ‘‘psychological’’ in character. At first blush, this seems a reasonable notion; but it needs to be nuanced. Obviously, if low body weight continues so will psychopathology and no therapy-derived insight is compelling enough to stand on its own in reversing the disease; behavior change is, of course, crucial to anyone’s definition of recovery; without weight correction the prospect for sustained recovery is nil. Just the same, there is no evidence—empirical or clinical—showing that normal weight is a necessary prerequisite for initiating meaningful psychological dialogue, or that psychotherapeutic dialogue can not be facilitative of weight change. It’s a bit like mixing apples and turnips. A patient 50 pounds below a BMI of 19—confused, disorganized, unable to retain short-term information, and emotionally erratic—is unquestionably ill-suited for psychotherapy of any sort. But this patient is considerably different from one who is 30 pounds underweight, ingesting food, and though compelled by similar fears is nevertheless committed to an examination of the conflict that has taken hold of his or her mind. Simply stated, normalization of weight is not the absolutely essential starting point for using thought, reason, and insight as foundations for change.

There is another paradox of sorts that needs mention here. A fundamental principle of FBT holds that parents must separate the symptoms of AN from the person who bears them. It’s an eminently sensible concept because the separation, if successful, can buffer against additional personal and family strain; especially for the patient, whose already harsh self-disparagement is injury enough. Just the same, there are histories in which parental attitudes, environmental strain, and psychopathology are not so easily segregated and the interventional efforts needed are more involved.

So our concerns are (1), the absence of support for many of the clinical assumptions the BBMI and FBT paradigms have given rise to, and (2), a philosophical attitude about treatment that is becoming far too circumscribed, moving in a direction that suggests—we now hear it stated often—that only techniques supported by controlled, empirical study deserve consideration. Again, to eliminate any misunderstanding, we are not contrarians assailing empirical research on biology or treatment techniques. Biology is an essential field of inquiry and the study of FBT by Lock et al. is a signal development with important implications. What we worry about is that many therapists have reified the effects of genes and took the results reported by Lock et al. to mean that FBT is the only justified treatment for young people with AN, overlooking the fact that 50% of the participants who received it were unremitted. In our view, the present disunity in our field underscores three worrisome trends: (1) that many therapists apparently see no place for the sort of clinical wisdom that can never be manualized; (2) that the emphasis on empirically validated interventions is drawing attention away from more broad-based training experiences; and (3) that therapists who will one day encounter very ill patients are not being prepared adequately for taking on the many complex predicaments they will face. In short, although it is without question that FBT will suffice as a first-line intervention for some young patients with AN (most likely those whose vulnerability load is less extreme), to insist it is the only treatment modality that deserves consideration doesn’t translate well for clinicians who have seen AN’s many faces over many years.

So the dialect underscores the need for attitudes about the BBMI and FBT paradigms to move in the direction of perspective taking: an appreciation of their value, but with finer distinctions that take into account knowledge gained from long-term clinical experience and translational research showing why a more inclusive vision of its complexity is imperative.

In one sense, that we have come to this critical juncture isn’t unexpected. In a field where soft ideas have long taken precedence, paradigms supported by empirically verified observations will naturally demand strong attention, as they should. But as we said earlier, there is a caveat: that belief about complex clinical issues is useful only if it portrays knowledge accurately and comprehensively. On the surface, the proposition is straightforward; in reality, it’s anything but; because debate over what we should or should not believe inevitably takes place in an interpersonal context of one person (or group) trying to convince another that the idea they have invested time and effort in is a fallacy. This is where the intellectual analysis of ideas becomes tricky, because human nature being what it is it doesn’t take much to violate the operative notion that this form of discourse must be emotion neutral. Realistically, the only viable solution to the problem of close mindedness is to carefully consider if the ideas we justify as knowledge are defensible regardless of personal ideology, and to resist turning a blind eye to ideas we may be inclined to reject spontaneously and uncritically. As a concrete example, it would mean that if we held strongly to psychoanalytic principals, we would not reject out of hand evidence of a cognitive mechanism operating in symptom formation. Cutting straight to the point, however strong our commitment might be to an ideology it should never cordon us off from considering the possible relevance of other concepts about human behavior.

So we unapologetically acknowledge that a purpose of this article is to challenge ideas tied to the BBMI and FBT paradigms that many now assume to be fact; to offer an understanding of why they hold only a piece of truth about AN—an important piece to be sure—but not a whole truth, and to see that when a less demanding theoretical and clinical calculus is applied to causal biology and psychopathology that is complex it inevitably faces disappointment. Our objective thus brings us to several touchy questions: Why do our treatments help some but not others? What brings well-intentioned care givers to do unwise things? And why has there been preciously little discussion at recent Academy meetings about the importance of approaching AN with diverse treatment skills?