Loved ones of those with eating disorders can find themselves feeling confused and helpless when treatment just doesn’t seem to be working, A psychologist, eating disorder expert, and a personal role model, Dr. Dana Udall-Weiner shares a bit of her wisdom here on NTS today about this difficult juncture in the recovery process.

When family members first learn that their loved one has an eating disorder, most are quick to ask an obvious question:  What’s the treatment?   Which is usually followed by another obvious question:  How long will it take?

Given that we’re talking about conditions with intimidating, Greek-derived names like Anorexia, it’d be easy to assume that medical and mental health professionals have this whole treatment thing figured out.  You’d think that all that data would lead us to a well-established treatment protocol—one administered consistently, reliably, invariably to patients around the world.  Something like an antibiotic for the food-impaired psyche.

Yet the reality is less constant and less comforting: Anorexia, Bulimia and Binge Eating Disorder are conceptualized and treated in various ways.  In the story of eating disorder treatment, there is a loosely organized narrative, with many disparate threads.

You can imagine the disappointment and frustration most people feel when they learn this stark fact.  You may have felt that way, too.

Though we’re learning more all the time, eating disorder research is still in its infancy.

Here’s what we know:  Eating disorders most likely develop due to a multitude of factors which include genetics, ongoing biological processes, and environmental influences.  They are not “caused” by mom’s poor body image or dad’s vegetarianism; they are not inevitable in the children of adults who meet diagnostic criteria.  But there is evidence for heritability:  People are more likely to develop an eating disorder when a first-degree relative has one.  And we know that parental eating patterns, as well as attitudes about weight, impact children—for better or worse.

Here’s the good news:  There are some treatments that seem to be relatively good at reducing eating disorder symptoms.  But the most important word in that sentence is relatively.  Relative to other treatments, Cognitive Behavioral Therapy is fairly effective for Bulimia and Binge Eating Disorder.  Relative to other treatments, Family-Based Therapy is fairly effective for adolescents with Anorexia.

Sadly, this tells you very little about your loved one, and how he or she will respond to treatment.   And that’s the bad news.

During treatment, some individuals very quickly gain insight about why their difficulties began.  For example, many Anorexics will tell you that they actually didn’t feel particularly fat before the eating disorder began to eat away at their lives; rather, they were experiencing something overwhelming—either external circumstances or their own internal response–which seemed impossible to tolerate or control.  The answer, they found, was to restrict their caloric intake; this, at least, seemed to grant them a sense of mastery over their bodies (and lives).  But even an insight as profound as this does not guarantee weight restoration or recovery; for this, the individual actually needs to eat.

The act of eating, however, is never as simple as piling food on a fork and directing it toward a waiting mouth, just as refraining from vomiting is never as simple as avoiding a toilet.  These behaviors have meaning, and they become part of a set of behaviors around which the individual organizes her life.

So why isn’t treatment more successful at getting people to abandon these worn out patterns?

Treatment can stall for a laundry-list of reasons which include: physiological factors (either associated with the eating disorder, or co-occurring and unrelated); psychological factors, including undiagnosed or untreated conditions; attitudes and beliefs about recovery; therapeutic factors that relate to the type of treatment being conducted, the setting in which it takes place, or to the therapist; and environmental factors, which include things like family influence and the media.

But regardless of why your loved one may have plateaued in treatment (or even failed to leave the starting gate), you can take important steps like these to right her course and encourage recovery:

1. Learn all you can about eating disorder treatment in order to determine whether your expectations are realistic.
2. Share your concerns with the treatment team and ask how they think things are going.
3. If necessary, get a second opinion; consult with another medical or mental health professional to get feedback about whether your loved one’s experience is typical or cause for alarm.
4. Think about whether environmental factors might be reinforcing the eating disorder.  Some things to consider:  Is your loved one participating in activities—such as ballet or gymnastics—in which a thin body is idealized?  Is she benefiting from the eating disorder in any way, such as getting attention from parents or increased respect from peers?
5. Talk with her directly to see whether or not she thinks she’s making good progress; it could be that her decision to refrain from “fat talk” with friends represents a major accomplishment in her eyes, even if she’s made little progress in changing her eating patterns.
6.  Educate yourself about which eating disorder symptoms are most dangerous, so that you can assess how she’s doing, make informed decisions about her care, and accurately communicate your concerns with her treatment team.  For example, poor body image is generally less worrisome than vomiting after meals.

In some ways, eating disorder treatment can feel like the Wild West—vast, loosely mapped, and ruled by contending factions who each want to stake their claim.  But even on stretches of unmarked trail, we generally know how to steer (willing) people toward health and wholeness.

It is not enough.  It is what we have.  And with additional years of ongoing research, our cartography skills will only improve.

If you’d like to learn the specifics about why treatment fails, as well as why research findings don’t always apply to your child, please watch my video, “When Treatment Stalls or Fails: Why Your Child May Not Be Getting Better.”  You can find it on my website, ED Educate, (www.EDEducate.com). 

I’ve had it with my patients. I’ve had it with my parents. I’ve definitely had it with my friends. It’s the exchange that goes like this:

Them: I’m so frustrated that I couldn’t [insert: overcome my eating disorder, become a better listener, lower my blood pressure, learn Chinese, be more romantic, stop biting my nails]!

Me: And why do you think that was the case?

Them: I know exactly. It’s because I was never truly doing it for me. I was always doing it for [insert: romantic partner, family member, boss, the trial judge].

Me: Oh. (said in a profoundly empathic way, with a few nods of the head).

My head nodding has was always genuine because I got it. You can’t make changes, real changes, without really wanting it. For yourself. Right?

I have to admit I’ve bought into this idea over the course of my life. And maybe it’s well-founded at times. Internal motivation is nothing to sneeze at.

But sometimes I think we use the idea that change has to be for us as, well, an excuse. We believe that if we haven’t truly summoned the will to change, it can’t work, and so there’s really no point in bothering with the whole shenanigan anyway.

Take eating disorder recovery, for instance, since it’s something in which I’m daily immersed. There’s a familiar refrain among not just patients, but other professionals too, that says: It’s not working because I’m (they’re) not doing it for myself (themselves). I’m (he/she’s) doing it because everyone else wants me (him/her) to.

Because I work mostly with adults rather than children currently, I agree that self-directed motivation is important for long-term recovery. [In the case of children, things get a little bit more tricky…] Individuals do have to want long-term recovery for themselves in order to sustain the immensely hard work that the process entails. Fighting against every urge in one’s being to engage in an eating disorder is much harder over time if the person doesn’t believe in him- or herself or his or her ability to do it.

But (and you knew that was coming), I do not think that means that recovery cannot at least start out for someone else. Here’s the thing – many individuals with eating disorders struggle with major issues around worthiness. They often believe that there is something inherently wrong, defective, or less than about them, and so the idea of taking care of themselves is foreign and, at times, abhorrent. So to imagine engaging in treatment – something that many even feel is indulgent due to these issues – feels awful.

If there is a relationship in their lives, however, that is important enough to them to even nudge them into recovery, I see that as a major point in their column. Individual: 1, Eating Disorder: 0.

When it comes down to it, all change has to start with a value, something we want for ourselves. We don’t just stop biting our nails because we stop enjoying it or it stops serving it’s purpose of relieving stress or boredom. We stop (when and if we do) because something else is more important. It could be the photographs that will be taken at our pending nuptials, our reputation among our co-workers who give us weird looks for our gritty little nails, or the fact that we realize that dealing with stress in this way is not particularly effective. Or, it could be because it irritates our partner to hell and we care enough about that person that we don’t want them to be irritated all the time.

The final reason is not a bad one, despite the bad rap that it often gets. We use the fact that we won’t or can’t change for someone else as a badge of honor or self-esteem. Hell, no, I won’t cut my hair for him!

But what if he actually has a worthy opinion, being outside my own head and all?

The fact is that relationships take compromise, and sometimes they are just the impetus we need to make healthier and better choices in our lives. Relationships can push us to do things we never thought we would – or wanted to – do, and sometimes with really great results. Wow, maybe I do look better with short hair… 

Of course, we have to manage our expectations — we can’t make another person love us or love us more with our choices. We can’t change into something that they approve of if the issues are deeper and less resolved. But sometimes, just sometimes, we can change for someone else. If we love them – and, ultimately, ourselves – enough to do so.

Below is one in the series of reader submissions called “If You Really Knew Me.” This moving post comes from an anonymous and brave reader. If you are interested in participating, check out the details.