To me, the idea of “treatment resistance” in eating disorders sparks some ill feelings. While many have suggested that treatment resistance is common among those with eating disorders, others have noted how receiving the label of “treatment resistant” can make it more difficult to receive needed support or impact how one is perceived in treatment settings and how one’s behaviours are interpreted (e.g., Gremillion, 2003).
Of course, this is a tricky ground to tread, primarily because sometimes people do resist treatment. Regardless, I think it is important to think about what lies behind the resistance to treatment. Is it the type of treatment? The people doing the treating? The compelling nature of the behaviours (e.g., restricting, binging and purging) at least in the short term?
In any case, to say that treatment resistance occupies a contested place in the eating disorder literature would likely be an understatement. Perhaps for this reason, I’ve more often seen treatment resistance featuring within explorations of other phenomena (e.g., outcome studies, qualitative explorations of the experiences of patients in eating disorder units) than as the focus of articles.
Abbate-Daga and colleagues (2013, open access) explored the body of literature on treatment resistance in eating disorders, trying to understand why many patients avoid or drop out of treatment. The authors suggest that understanding treatment resistance might help improve outcomes for people with eating disorders by assisting in tailoring supportive treatment geared toward patient needs.
This article provides a review of the literature on treatment resistance. The authors conducted a systematic search of common journal databases and found 142 articles about treatment resistance. From these, they selected 71 that fit their inclusion criteria (AN diagnosis, English language, original research/debate article, published between 1990 and 2013).
Their goal was to look at trends and findings from the diverse studies to explore:
- Why patients might express a desire for treatment and recovery and yet not improve
- How resistance (both conscious and unconscious) features in eating disorders
Study types ranged from qualitative explorations to randomized controlled trials, among others. Because of the diverse nature of the literature, the authors grouped studies into 4 areas:
- Illness awareness
- Patient willingness
- Psychopathological factors related to eating disorder symptomatology
- Therapist aspects
Within these categories, they explored the following tensions.
Denial vs. Insight
Of the 71 studies, 7 focused on denial of illness versus insight into illness. In general, researchers found that the longer someone had been ill, the more insightful they were about their illness.
However, studies differed in describing how such insight impacts resistance to treatment. Some researchers suggested that the more aware and insightful someone was about their illness, the more likely they would be to comply to treatment; others argued that this was not a significant predictor of compliance/resistance.
Instead of being predictive of treatment resistance (as might be inferred by its inclusion in diagnostic criteria and/or assessment prior to entry into treatment), the authors note, treatment resistance might co-occur with denial. Moreover, it is unclear if denial is tied more to “psychosis-like” elements of disorder or if it is a defense mechanism. I wonder; is it always one of these two? Could it be both, or neither? This is an interesting area that warrants further exploration.
Motivation to Change
A bulk of studies (33) looked at how motivated participants were to change. Overall, this body of research indicates how important it is to consider motivation both prior to and during treatment. The authors argue, however:
It is noteworthy that those motivations verbally expressed by patients often do not correspond to an authentic intention to modify their eating disordered behaviors since ED patients can be strongly ambivalent about changing (p. 6)
This one is tricky. While this might certainly be true, I do think it is important to avoid making it sound as though people with eating disorders are being sneaky. Who is to decide what someone’s “authentic” intention is? It is important to stress that this isn’t about people with eating disorders necessarily lying about their motivation to change; perhaps it is more about the difficulty of actually enacting change, even when someone wants to change.
Tied into motivation to change, studies explored by Abbate-Daga et al. also examined how motivation to change can be impacted by several factors, including (among others):
Body and weight preoccupation
- More body/weight preoccupation has been linked to lower motivation, more ambivalence about behaviour change (Ricca et al., 2010; Konstantakopoulos et al., 2011; Steinglass et al., 2007)
- BN diagnosis (vs. AN) is linked to treatment motivation (Casanovas et al., 2007)
- AN-binge purge subtype is correlated with low responsiveness to treatment (Salbach-Andrae et al., 2009)
- EDNOS has been linked to a speedier and more stable return to symptom remission and a higher motivation to change (Ben-Tovim et al., 2001; Herzog et al., 1999)
- A moderate BMI has been linked to greater motivation to change (Geller et al., 2009)
- In the short and medium term, more rapid weight gain may enhance motivation (Lund et al., 2009; Mewes, Tagay & Senf, 2008)
Motivation to change appears to be tied to treatment resistance, the authors suggest, through the stages of change; that is, when the stage of treatment is closely linked to the individual’s level of motivation to change, they are more likely to respond to treatment.
Twenty-two studies focused on treatment outcomes and possible reasons for the limited success of interventions. Despite a recent move away from looking at maintaining factors, some studies still seek to isolate or refine a model that could account for eating disorders. The basis behind this, of course, is that if we know what causes and sustains eating disorders, we can be better equipped to manage them.
Much of what the authors explore in this section is echoed in the eating disorder literature in general, so I won’t go into detail here. In brief, the authors refer to Fairburn’s model of interacting ED-related and general factors (e.g., relevance of eating, weight, and shape for self-evaluation, self-esteem, perfectionism, difficulty managing emotions) and list a number of other individual (e.g., personality, emotions, relational skills) and social (e.g., caregiver factors, treatment factors) that can lead to eating disorder persistence.
Obviously, many things can impact treatment course. The “perfect storm” of factors could certainly lead to a chronic persistence of the eating disorder, which seems to be the point the authors are making. Further, they suggest that chronicity means that we need to explore what kinds of treatments might challenge these factors and their interaction to minimize resistance to treatment and improve outcomes.
The therapeutic relationship, including perspectives from clinicians and individuals in treatment, featured in 18 studies. The authors explain that these studies had conflicting methods for improving experiences and outcomes for patients who resist treatment.
Among things that can facilitate successful outcomes, studies suggested:
- Looking at patients’ motivations (Carter et al, 2012; Karlsson, Clinton & Nevonen, 2013)
- Treatment tailored toward specific patients, using a rehabilitation perspective (Tierney & Fox, 2009; Strober, 2004)
- At times, discharging patients who do not wish to be treated in order to maintain a therapeutic environment for other patients (Masson & Sheeshka, 2009; Vitousek, Watson & Wilson, 1998)
- Working with therapists to explore their own emotional reactions to patients (Forget, Marussi & Le Corff, 2011; Satir et al., 2009; Thompson-Brenner et al., 2012)
- Focusing on patient-therapist interaction and making decision-making processes more equitable (Darcy et al., 2010)
Several also suggested using interventions that directly address treatment resistance, for example:
- Focusing on motivation to change and providing emotional validation (Vitousek et al., 1998)
- Using motivation enhancement strategies, like Motivational Interviewing (Moyers & Rollnick, 2002), Readiness and Motivation Therapy (Geller, Brown & Srikameswaren, 2011) or Motivational Enhanced Therapy (Feld et al., 2001)
SO, WHAT DOES IT ALL MEAN?
The authors have taken a very diverse body of literature and distilled it down into a coherent exploration of treatment resistance. As they note, looking at treatment resistance means taking a number of different angles: what patients think (by asking them to talk about it and through having them fill out scales that might show differences in terms of quality of life, motivation, etc.), what clinicians think, and what other intervening factors (social and biological) might exist and impact treatment resistance.
While 71 studies might seem like a lot, it is actually not that much to go on, especially when the areas of focus and conclusions are diverse. The authors suggest that the literature might be sparse because treatment resistance:
- Might “be easy to notice but difficult to understand” in that it is common but hard to isolate a cause for
- Is often seen as part and parcel of eating disorders, in the clinical practice world
- Has not been a major focus in social/clinical studies as researchers have been preoccupied with determining whether there is a biological basis for resistance in eating disorders
Most interestingly to me, Abbate-Daga et al. note that one of the main reasons why treatment resistance has not been a major focus of many studies is that clinicians might hesitate to study what could be seen as a “failure” in their treatment methods.
Looking at motivation to change, the authors allude to the need to complicate what we mean by “motivation,” and whether people follow a clear and linear path in terms of motivation. Could part of the discrepancy observed between expressed and acted motivation be due to the desire to please treatment providers or loved ones, or (at least in part) linked to changes in emotional and physical states?
I find the authors’ suggestions for navigating the tricky terrain of motivation vs. ambivalence quite compelling: they note that it is important to demonstrate empathy and work on exploring with patients what some of the positive and negative elements of the disorder have been for them. While this seems pretty straightforward, the willingness to consider what the eating disorder has provided for patients remains a less common practice.
I am also encouraged that the authors advocate for an approach that recognizes the individuality and complexity of eating disorders in general and resistance to treatment in particular. At the same time, they recognize that it is not so easy to take a very individualized approach to treating eating disorders: we face an economic climate wherein resources for individuals and treatment centres alike are sparse; are insurance companies more likely to take the time to assess the needs of a particular case, or hold onto whatever limited evidence there is for the benefits of one type of treatment?
This is a key question in the field in general, and one that is not limited to treatment resistance: how can we match the complex needs of people with eating disorders to limited resources? Who is responsible for ensuring that people’s needs are met, and that the type of treatment people are receiving is appropriate for them? I could rant about this for hours, so I’ll leave it here, but suffice to say that treatment response, outcomes, and appropriateness is a complex issue with individual, relational, social, and systemic investments.
Abbate-Daga, G., Amianto, F., Delsedime, N., De-Bacco, C., & Fassino, S. (2013). Resistance to treatment and change in anorexia nervosa: a clinical overview. BMC Psychiatry, 13 (1) DOI: 10.1186/1471-244X-13-294