What makes psychotherapy work? It's the client!

Despite my reputation for being "only about the food," the truth is that I'm a huge fan of therapy. And skilled therapists. I'm intolerant of poorly conceived therapy and undertrained therapists.

The biggest problem with eating disorder therapy to my mind is this: What makes psychotherapy work? It's the client!

But eating disorder patients are anosognosic: they aren't able to grasp their own state of mind and emotion and cognition UNTIL THE BRAIN IS REPAIRED.

Engaging in therapy requires a functioning brain. It requires motivation and engagement and cognitive flexibility. It requires self-awareness - and eating disorders rob the brain of that while the body is still undernourished. And by nourished I don't just mean weight restored - I mean the brain damage is repaired. I mean you need full weight restoration, behavioral stability, and then a few months of healing FIRST.

I think therapy while a person is still brain damaged or acting on ED compulsions by binging or purging is like therapy while drunk.

If you showed up for your appointment drunk or high, I don't think it would be ethical to sit and explore your issues or review your week. But people routinely show up for therapy while underweight, having recently binged or purged or over-exercised.

It is time for a zero tolerance for continuing brain damage during eating disorder treatment. An end to minimum weight goals, of "out of medical danger" as a standard for recovery, and of "improving" as a measure of success.

For all patients, from the day of diagnosis, period.


  1. I can not agree more. This is a terrific justification on top of everything else we know for utilizing Maudsley/Family Based Treatment. Oftentimes, individual therapists report hesitation as they so value the individual therapy relationship which traditionally is the foundation of change however as you soeloquently point out how can you effectively develop an authentic foundation for any relationship while under the influence of ED. Therefore, focusing on weight/nutritional restoration first and foremost provides the foundation and then the individual therapy and work can begin after restoration. I discussed this last night in group and it seemed to be helpful for parents to hear as at times parents report feeling like they are invading their daughters treatment when seeking to be more involved, this also says something of the therapist and the approach the therapist is using if they are feeling as though they are invading verses invited! Stephanie

  2. I do think therapy can provide a good sounding board and sympathetic ear while refeeding is occuring -- In addition, I found learning CBT and DBT WHILE refeeding was helpful -- these are strategies that can be used to quell discomfort related to refeeding and obsessive thoughts of anxiety. Group discussions and individual sessions did help to get out feelings, distorted thoughts, frustrations, etc.

    However, interpersonal therapy -- the REAL useful therapy can only really be done once weight restored and healed -- I agree with you there. The focus on therapy during an eating disordered period is -- well, the eating disorder. This is counterproductive.

    The problem occurs in the adult system where the patient is actively engaging in an eating disorder. The focus of therapy is the eating disorder and although the therapist may PREFER the patient recieves full nutrition/weight restoration, he/she cannot legally force the person into treatment or not to use the ED as a coping mechanism. The therapist can only make recommendations -- whether the patient heeds them is their choice.

    Yes, there is a big dispute over whether patients are rational while in their ED's So far, I don't believe there has been any conclusive evidence either way and I believe it varies on the individual.

    I know Maudsley counts on irrationality of the patient -- this makes sense in children because children are NOT ready to take care of themselves regardless of their ED and have no longterm planning or ability to see consquences.

    However, I have seen many adult patients recover with the help of traditional treatment -- themselves -- making the choice to eat and gain weight -- themselves -Some of these women/men have remained healthy for over a year now above a minimum standard of health. In the adult system it depends upon the motivation. I guess that is a problem from the parents perspective when the adult child is set on starving themselves to death. . .

    It is a giant conundrum.


  3. Good points, to add to my note, I tend to find that individuals actively under the influence of the eating disorder tend to show signs of irrational thinking directly surrounding the ED however are cognitively intact to say the least relating to issues outside of weight, shape, appearance and such matters. It is difficult as I find that the ED tends to be as intelligent, motivated, etc. as the bright, intelligent and amazing people with the eating disorder. BTW, I am huge advocate of CBT-DBT in general and utilize in conjunction with Maudsley approach!

  4. I agree with you, Laura. I think some of the traditional kinds of psychotherapy are actually harmful while someone's mind is under the control of the illness. For example, some models of family therapy encourage family members to acknowledge the validity of their loved one's anorexic thoughts. Doesn't that give more power to the illness?

  5. Laura, do you not think there is value in regular contact with a therapist even while the individual is underweight, for the purposes of providing general support (you are being heard, I will continue to help you, I know this is hard, I care about you, etc) as well as for building rapport (so that as the brain heals there is a therapeutic relationship in place to start doing real work)?

  6. I do. I'm all for that - but only if the nutrition part is happening - fully, every meal.

    Full nutrition from day one. And if they can't do it on their own, someone else in charge (parent, loved one, inpatient...).

    Like I said, therapy is GREAT, and the therapeutic relationship can be critical - but while still symptomatic that relationship is between the ED and the clinician.

  7. Chartreuse -- What do you mean by "doing real work"? I don't understand that concept.

  8. Anonymous -- I meant in general using psychotherapeutic techniques to achieve goals. For example, challenging cognitive distortions, encouraging more adaptive methods of self-soothing, exploring past traumas, etc. That is, useful psychotherapy is generally more than just being supportive, but for someone who is deeply underweight (or deeply depressed, typically) maybe it's not possible to do more than that.

  9. I think that going to therapy while drunk is better than not going at all...therapy is what got me to eat in the first place. No one else did.

  10. I agree and disagree. I think Maudsley is the most successful approach there has been thus far. However, there are a limited number of people who can do it for about 3 reasons. One, because most who specialize in this approach only work with children/adolescents; two, very few specialize in it; and three, many adults w/ EDs don't have the same support from family as kids/adolescents.

    I don't have a real close relationship w/ my family, but even if I did, they live 28 hrs away and they both work. There are no Maudsley specialists in my state. In fact, I have to drive 68 miles just to get to the closest eating disorder specialist. I have to drive 42 miles to get to the closest support group. Neither the support group nor the therapist care for the Maudsley approach much (or even know much about it, except that they don't agree w/ it!). Luckily, I don't go to that support group or see that therapist anymore. I drive a few additional miles further in order to see a better specialist. Although she knows some about the Maudsley approach and doesn't oppose it, she also doesn't know a whole lot about it and both of us are unsure how I could do it anyway. Additionally, there are no inpatient eating disorder hospitals/treatment centers in my state, and my insurance won't pay for me to go out of state.

    Right now, my option is my psychotherapist. She listens and does her best to encourage me. Sometimes, that encouragement leads to me eating slightly better. Sometimes not. However, she always keeps me hopeful. She helps me believe there's a reason to keep trying. She always keeps me believing that one day, I'm going to figure this out and be able to move forward w/ my life.

    So, while I think your idea is great, I don't think it's realistic at this point. If more therapist would practice Maudsely, and if more researchers would study how it can be used for adults... then maybe one day.

    All I can be right now is hopeful.

  11. I agree that the starving mind will find it difficult to engage with traditional therapy and that at worst, therapy can end up validating the ed rather than the person trying to get the monster off her back.
    However, as A pointed out, what is a therapist to do with an adult client (who may or may not have a family in the background who would be willing to give taking charge a go, but who won't be about to suggest it)? The philosophical argument against therapy while drunk can leave the therapist with no other option but to say "come back when you're sober". This COULD absolve the therapist of doing harm, on the other hand it could leave the patient to "sod off and starve" as a dear (anorexic) friend of mine put it.
    This conundrum is why I am so interested in Janet Treasure's "Motivational Interviewing" techniques - in the ed specialist playing a part in preparing the patient to get well both mentally AND physically, rather than just waiting for someone else (who? the exhausted, absent or abusive parent? the anosognostic patient? the clueless general physician?) to get the patient ready, or not as the case may be.

  12. I'm actually not talking about Maudsley here. I'm talking about changing the standard for clinicians: do not treat people with psychotherapy unless they are verifiably and consistently "sober."

    That means from first diagnosis a patient is monitored medically and unless there is consistent weight gain (if needed) and an end to bingeing and purging then the patient is put under the care of someone else: if a parent is available, great. If a spouse or other caregiver, fine. If not, hospital or inpatient or residential.


    I think therapy, while still "using," is enabling the illness.

    And I know this has practical issues - but the 'system' doesn't work now. Patients wander around in charge of their own nutrition and get sicker - and we all wave our arms in alarm and disapproval. But it isn't their fault, it is ours - as a society. We treat people as if they are making a choice, and we have to respect it.

    I submit they are under the control of an illness. And we are enabling it and keeping them ill.

  13. in so many ways I agree with you entirely, but we'd have to change the whole of society, not just medicine to get a system which treated irrational behaviours as sick but continued to treat the person with the illness with dignity and respect. Quite rightly there is much hand wringing over the dreadful injustices done to people with all sorts of mental health problems (and none!) when locked up against their wills and against their genunine better interests in old fashioned asylums - but unless we can make the whole of society an asylum from detrimental behaviours (which we don't seem to be able to manage with alcohol or drugs let alone with dieting) what else is there to do?
    an enabler.

  14. When DD was at her sickest, nothing in her therapy "worked". And none of the clinicians put together the fact that in order for you to work on your brain, your brain has to work!

    And you should have seen the look on our family T's face at the point when I asked her "So how is my anxiety affecting (daughter's) encephalopathy? Wouldn't you be worried about my cognitive dissonance if I wasn't anxious about (daughter's) STARVATION?"

    As our daughter is now almost 4mo weight restored, we are continually amazed at how fast her progress in her therapy is!

    It's a matter of the right treatment at the right point of the disease.

  15. I also find it interesting that in most adult hospital programs for ED's in Canada at least -- bedrest almost doesn't exist.

    I read a study published by the University of Toronto, IP director which said that the "fog" of starvation often lifts (contrary to popular thinking) almost over a few days of full nutrition -- Patients with BMI's of even 10 or 11 can be incorporated in groups and benefit from the therapy. . .

    Personally, I think therapy is important for an adult ED sufferer as Marcella pointed out, to begin to motivate the individual toward change. I believe there is research being done for this type of motivational therapy?

    Besides that, I do not know what you can do for chronic ED sufferers. Maudsley will work with the consent of the adult patient (similar to any treatment which works with consent or motivation) -- But it is almost like looking at an entirely different disease than child/adolescent AN by the time the patient reaches the mid twenties/early thirties.

    Studies show that forced treatment (at home or in hospital) DOES work with weight restoration but not long term -- eventually the patient does have to take responsibility for their illness --even in Maudsley, there cannot be an eternal stage one.

    It really is a devastating illness. I find professionals also tend to "ignore" patients who do not wish to recover or struggle greatly. These are the patients that most need help and have a tendency to become chronic.

    For example, if you remember me from last year, I did have a BMI of 20.5 -- dropped to a BMI of 14.8 after leaving treatment for non-compliance -- However,I was struggling and cutting me loose was probably to worst they could do. I am now up to a BMI of 15.5 with the help of a private practice dietician.

    What is the family/patient to do when they have been "cut" by the healthcare system. Sometimes psychotherapy is the ONLY route left.

    I know I have raised many random thoughts. . .

    Interesting discussion!


  16. Oh, A:) -

    I am so sad. I hate this illness and I hate the "system" which lets you remain ill. Is there someone you can entrust with your care?

  17. I have a great team -- so I am trying to do this by myself, step by step. I have been able to gain some weight, although it is like pulling my skin off. . .

    Small steps and hopefully I will eventually get back to where I was.

    I won't go into another program as the anorexic "subculture" is just too toxic.

    Thank you for your caring,



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