Management of Patients with
Intractable Eating Disorders
Despite treatment advances, eating disorders of all types may prove refractory to treatment. Intractability may be associated with persistent physical, psychological, behavioral and social impairments, and contributing factors may include temperament, coping styles, comorbidity, and the quality of social support and treatment available. This chapter is concerned with the management of patients with such problems.
If patients do not agree with their treatment plan, little of substance is likely to be accomplished. To establish the rapport necessary for effective treatment alliance, clinicians must treat patients with respect and integrity, and convey by word and deed that the patient’s well-being is their primary concern. Effective clinicians often convey affection for patients, proactively perform small acts of kindness, and show empathetic understanding for patients’ feelings of despair, defiance, and mistrust. Clinicians lacking these qualities are often experienced as uncaring and coercive.
Patients with intractable problems vary in their motivation to change. Some maintain a sense of self-efficacy by convincing themselves that they want their symptoms. Others identify with aspects of their eating disorder psychopathology, particularly the pursuit of control over eating, shape, and weight. Some fear even contemplating the drastic changes required to overcome their disorder. Clinically, these patients appear unmotivated. Poor motivation may also result from the patient’s judicious and experience-based appraisal of