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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

Other Clinical Challenges: Why Experience, Skill, and Complex Ideas Matter

Thus, the question arises: How well are the current emphases on biology and manualized treatments preparing young therapists for the challenges they will soon encounter? And given recent attention on outpatient, family-based therapy and the strong allegiance pledged by many therapists to the model, let’s also consider the question of whether or not AN’s more extreme morbidity is being taken too lightly. Unfortunately, here, too, the concerns are justified.

We have recently crossed swords with providers oddly opposed to hospital-based care, not only for patients at low weight for periods ranging from months to years, but also for those whose weight was on the decline. The argument has been that inpatient treatment is ‘‘known’’ to be ineffective (in fact, there isn’t a stitch of evidence that supports this statement), and that if their patient is exposed to ones hospitalized they will only learn dishonesty and deviousness; yes, this can happen. But the logic here is so obviously tortured you wonder how it leaves someone’s mouth uncensored: ‘‘I insist on protecting my patient by maintaining the present treatment course at the risk of even greater weight loss, further bone decay, more psychological malaise, and an even stronger conviction that weight loss is the ultimate salvation.’’ It’s this sort of foolishness that leaves anyone experienced in the care of very ill patients scratching their head in bafflement and dismay. Perhaps more irritating is that this absurdity is almost always argued by therapists who have never worked in a hospital setting. Of course hospitalization carries significant risk; we hear the horror stories quit often. But the problems arise mainly in settings where the treatment approach is either incoherent or coercive; because the program’s leadership and staff are minimally skilled and the treatment philosophy is superficially narrow and pedestrian. Sadly, the effects of poor treatment, no matter where it takes place, can be far reaching. Beyond the branding effect—all hospitals/day hospitals/therapists should be avoided—the lack of geographically accessible, high-quality inpatient programs (or limited availability of skilled therapists), only compounds the problem. But shrill attacks from practitioners who know little to nothing about the high quality of care that is possible in well-regarded treatment centers and who fail to grasp the urgency of intervening with more intense levels of management when AN advances are difficult to stomach.

The Therapist’s Task

Judging the intensity of the dispositional traits that foreshadow AN is a critical task; this is because once irrational attitudes about weight, appearance, and dietary restraint unfold these factors play a role in driving symptom intensities, their resistance to rational argument, and the strength of the reward weight loss brings. To have this knowledge is to be forewarned because when extreme habit rigidity and anxiety converge, AN’s remedy is far more difficult and the self-belittling ideas, shame, and convictions of inadequacy that patients harbor are highly resist to challenge. So taking into consideration how difficult it is to predict the future, we come to the question: How, and when, should we react to malnutrition that is not reversing? Intervening early offers a potential advantage, but even then treatment is beset by challenges for which immediate, easy to effect, solutions are sometime lacking. This is why the question is a crucial one. But first we consider some other treatment-related challenges for which solutions are not always immediate.

One is the grim reality of finite resources. Motivation for treatment may be strong and family support unwavering, but if funds needed to support an extended period of care for a dangerously underweight person at a respected treatment program are not available, alternative solutions may be few; this is a circumstance that can only be described as heart wrenching.

A second is no less urgent, but is more universal: that of treatment refusal or nonadherence, a challenge that becomes especially worrisome when patients are at the age of consent. Avoidance of care in AN is not so much a battle of wills as a confrontation between opposing values and perspectives—of patient, family, and practitioner. Having been a part of the struggle more than once, it is hard to capture in words the urgency of a family’s desperation, our own as well, when a dangerously wasted person enters a courtroom to serve as a platform for legal debate about mental competency and the freedom to choose one’s fate. The debate is less contentious when risk of death is imminent and mental deterioration is indisputable, but only because there is no legal barrier to physician intervention within a medical facility when risk is imminent; even the most zealous patient rights advocate shies away from a defense of free choice under these circumstances. It’s when the sufferer appears capable of satisfying the broad legal definition of competency in spite of malnutrition that the outcome is less certain. Having sat through the proceedings many times, there isn’t prose strong enough to describe the tension—parents and loved ones, therapist, too—all obliging court etiquette by gritting teeth in order to remain silent witness to legal arguments that defy reason.

This is why the question of what can be done before the opinions of attorneys and judges are engaged is so important. And shouldn’t these issue come up for detailed discussion in the very first contact with a potential patient (and family)? Isn’t this the logical time to prepare them for what is to come, both in general and in the many particulars of the illness, in the hope that a travesty can be averted—to discuss the nature of AN, what drives incomprehensible objections to weight gain, what in the case history might impact on long-term outcome, and the different levels of care that may be needed? This is the role of consultation, a task far different from motivational enhancement (again, see Waller’s19 cautionary points). We would argue, and strongly, that for an illness as challenging and enigmatic as AN consultation is an essential prerequisite to the initiation of treatment; unfortunately, it is frequently ignored, as we will show. Our point in citing these examples is that given the challenge they entail, it is difficult to sustain a case for teaching about AN that focuses on narrow ideas and narrow clinical training.

We naturally hope for our science to become more generative, but in the meantime it isn’t as if we are completely in the dark. Managing AN is hard, but at least some of the challenges can be tempered if met by a clinical wisdom that is appropriately balanced by humility; unless we are too hostile to some ideas and too favorably disposed to others. What we hope we have made clear is that to successfully integrate pragmatic strategies supported by clinical research and experience into an overarching management that better assists patient and family, clinicians must know about the science outlined above, learn how it applies, and come to the work very well prepared. It’s when the challenge is met by inexperience and skills narrowly developed that fear takes hold, and the impulse to see the illness in more categorical terms—to insist on the superiority of single, specific interventions— will be strong; we have seen this many times in supervising the casework of less experienced therapists. Maintaining poise as symptoms escalate is difficult under any circumstance, but when training and experience lack diversity and depth the straightforwardness of less abstract concepts becomes appealing. Simply put, experience too limited and clinical training too selective will bring frustration and fear should the initial presentation be severe, should progress stall, and should weight start to decline.