Eating Disorders and Motivation: Some Meaningful Clinical Strategies Are Rooted in Attachment Theory

By Scheel, Judy | Addiction Professional, May-June 2012 | Go to article overview

Eating Disorders and Motivation: Some Meaningful Clinical Strategies Are Rooted in Attachment Theory


Scheel, Judy, Addiction Professional


Eating disorders are often difficult to treat, due in part to many patients i being ambivalent about recovery. In a recent article published in the International Journal of Eating Disorders, practitioners are cautious about being too optimistic or invested in patients' motivation. (1) The authors suggest that motivational methods alone show little evidence of being effective. Motivational techniques need to be operationalized, and behavioral change is crucial. While verbal expressions of motivation are relatively unhelpful, it is important and moderately helpful to assess the patient's level of motivation upon entry to treatment.

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Embracing two additional premises also can be useful when considering facilitating a patient's motivation to recover from an eating disorder. First, eating disorders are adaptive; they serve many purposes. Second, engaging in and sustaining a positive therapeutic alliance based on empathy, trust and respect is necessary for sustained motivation. Attachment theory can provide a framework for this to occur.

The causes of eating disorders are complex and unique to the individual. Seeking help is generally fraught with conflict and ambivalence, because often the person is in significant emotional despair by the time he/she is ready to take steps toward recovery. Other times, seeking help comes as a result of medical necessity. What contributes to motivation for recovery can vary among individuals. Their reasons for beginning treatment may stem from reaching their own psychological, symptomatic and relational bottom to perhaps being on the verge of death as a result of starvation or purging.

Helping patients find their motivation for recovery can sometimes be hampered by the circumstances under which they "accepted" the need for treatment. Was it from their own will to recover? Perhaps treatment was sought because of terrified family members watching their loved one fade away. In all cases, helping patients discover their own reasons to begin the recovery process contributes to creating and sustaining motivation. Viewing eating disorders as an effort to adapt to a life that is out of control, and integrating a relational approach in treatment, can help them on this road.

The functions of eating disorders

Biological underpinnings as well as familial, environmental and cultural elements all can contribute to the development of an eating disorder. While research into genetic links continues, treatment options are plentiful and usually include combinations of relational approaches, cognitive-behavioral treatment, family treatment and psychiatric medication.

Eating disorders can act as replacements for relationships. Often, they coexist with other issues such as depression, anxiety, personality disorders and substance abuse. Eating disorders with substance use are especially associated with the highest mortality risks across all mental disorders. (2) Alcohol and stimulants are most commonly abused among patients with eating disorders, and substance use disorders are reported more frequently in patients with bulimia than anorexia. (3)

Yet, whatever the root cause, eating disorder symptoms and behaviors provide calming effects, such as the thought, "If I don't eat, I don't feel." Purging provides the release of painful and negative emotions, and has a physiological calming effect over mood. Symptoms are also "affect enabling' in that individuals physically feel through the act of purging or hunger in lieu of psychologically experiencing emotion.

Symptoms also serve to regulate affect in that the person projects feelings and conflicts onto the symptom (feeling guilt or shame because of purging rather than perhaps thinking about what in the person's life causes feelings of guilt or shame).

Eating disorders also are metaphors. They represent symbols that individuals are unable to express and experience emotionally, verbally and relationally. …

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