When someone you love is struggling with an eating disorder, the need for treatment feels—and is—quite urgent. After all, eating disorders are the second deadliest mental illness, and the earlier someone gets treatment the better their chance at lasting recovery. But for your loved one, treatment might not feel urgent at all. In fact, it might be the last thing they want to do.
As a person progresses toward recovery, they almost always get on board with treatment: both weight restoration and the cessation of eating disorder behaviors help them gain more insight into their illness and see the value of treatment. But how do patients ever get to that point if they resist any care in the first place? Indeed, initiating treatment can be a tricky task when the person who’s ill doesn’t want to go through with it. With the right strategies and resources, though, friends and family members can successfully guide those they love toward recovery. Read on to learn how.
Anosognosia in eating disorders (or why someone might resist treatment)
There are two fancy words that help explain why those with eating disorders may resist treatment: anosognosia and egosyntonic. While both are tongue-twisters, they have fairly straightforward definitions that shed some light on what might be going on in the mind of someone who’s struggling.
When I was initially diagnosed with anorexia over 20 years ago, a lot of medical professionals threw a lot of words at me I didn’t understand. In addition to “amenorrhea” (lack of menses) and “anhedonia” (reduced ability for pleasure), one of the strange words scribbled in my chart was “anosognosia.” It wasn’t until years later, when writing about mental health for a national outlet, that I learned the term’s meaning: an ill patient’s belief that they are not, in fact, ill. “Anosognosia is the lack of awareness that one is sick and it’s a common eating disorder symptom,” says Equip Therapist Lead Lainy Clark. “This is also generally called a ‘lack of insight’ and results in an inability to recognize the need for help.”
Then there’s the fact that eating disorders are egosyntonic. Something that’s egosyntonic is aligned with a person’s self-image, values, and feelings—which means that a person with an eating disorder might know that they have one, but they don’t want to get rid of it. Of course, it’s only the distortions of the eating disorder brain that make someone feel aligned with the values of their disease, but given the stranglehold an eating disorder has on a person’s mind, this feeling can be quite powerful.
“Without any intention to do so, many patients automatically go to minimizing symptoms and the need for intervention,” says Jenna Robinow, LMSW at therapist at Equip. “Part of anorexia, for example, is ambivalence toward its negative impact on a person's health. Malnutrition gets in the way of seeing the urgency of getting treatment clearly and acting on it. In that sense, it can be unfair to assume that someone in the throes of an eating disorder is going to be on board from the start.”
What resistance to treatment might look like
According to Clark, resistance to treatment can manifest in myriad ways. “The most common is emotional dysregulation resulting in pushback, outbursts of anger or rage, and crying,” she says. “Unwillingness to participate in treatment sessions, aggression, and increased hostility toward others are also some common forms of resistance.”
In addition to emotional outbursts and aggression, Equip Dietitian Tanya Hargrave-Klein says many patients may plead to get out of treatment by promising to attempt recovery on their own. Others may throw food, curse at their support network, or give loved ones the silent treatment. “This might include not returning text messages, not answering their phone, or not acknowledging support people in person,” she says.
While it’s tough to know how frequently this kind of opposition occurs, Hargrave-Klein says it’s very common. “It’s expected for a loved one to experience resistance to engaging in treatment,” she says. “It’s also very typical for a loved one to want treatment one moment and then be opposed to it the next moment.”
How to help someone with an eating disorder who doesn't want help
While there’s no one-size-fits-all strategy that will work for every family, there are some tried and true tactics that can help gently encourage individuals in the right direction:
- Acknowledge and validate their resistance. “It’s helpful to acknowledge what you are observing and validate your loved one’s feelings,” says Hargrave-Klein. “That might sound something like, ‘I can see that you don't want to start treatment. That makes sense because it feels scary and because you don't know what to expect and because it isn’t something your friends are having to do.’”
- Initiate open, honest, collaborative conversations. “Help your loved one fact check or reframe some of their greatest fears about stepping into treatment,” Robinow advises. “Processing and getting curious about their resistance may actually diffuse some of their fears, which feel enormous in their head but may be broken down into more manageable hurdles that can actually be overcome with support.”
- Allow unconditional space for them to express their feelings. “Don't assume you know how your loved one is feeling,” Robinow says. “Tell them what you are noticing in their behavior and allow them to tell you what their internal experience is like. This may support a more collaborative effort.”
- Consider treatment options that are effective despite a loved one’s reluctance. “The symptom of anosognosia makes evidence-based care like family-based treatment (FBT) an accessible and effective option for recovery,” Clark says. “The home environment inherently helps facilitate a loving and firm recovery journey, despite the patient’s lack of insight. The temptation to use logic and rationale to get our loved ones to understand their need for treatment is understandable, but we must remember the effects of malnutrition and anosognosia will result in our loved one being unable to access these facts in the beginning.”
Helping a loved one understand the need for treatment may take a significant amount of time, but Clark says it’s important to continue focusing on the aspects of the journey within your control. “We can see continued resistance and lack of insight for months during weight restoration,” she says. “Hoping your loved one will ‘get it’ and be receptive to treatment might not be realistic. Instead, it’s more helpful to focus energy on being loving, empathetic, and supportive while also speaking truth and remaining firm in what you are asking your loved one to do.”
It’s also important to remember that each individual and family is unique and it may take some trial and error to find which strategy helps get through to a loved one who is in need of help. “For some, it can be helpful to focus on how their life might be different without an eating disorder,” says Hargrave-Klein. “This might include being able to participate in a sport, hang out with friends, or go on family vacations. For others, it might be helpful for family members to reassure their loved one that they won't be recovering alone; family will be supporting them along the way. And it's important to keep in mind that family members do not need full buy-in from their loved one to initiate FBT. Family members can choose recovery for their loved one until their loved one is strong enough to choose it for themself.”
If you're concerned about a loved one struggling with an eating disorder, schedule a call with an Equip team member. We can talk through our program, how it can work for you and your loved one, and how to help them get started even if they don't want to right now.
- Attia, E. and Roberto, C.A. (2009), Should amenorrhea be a diagnostic criterion for anorexia nervosa?. Int. J. Eat. Disord., 42: 581-589. https://doi.org/10.1002/eat.20720
- Gorwood, Philip. “Neurobiological mechanisms of anhedonia.” Dialogues in clinical neuroscience vol. 10,3 (2008): 291-9. doi:10.31887/DCNS.2008.10.3/pgorwood
- Acharya AB, Sánchez-Manso JC. Anosognosia. [Updated 2022 Jun 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.
- Gregertsen, Eva C et al. “The Egosyntonic Nature of Anorexia: An Impediment to Recovery in Anorexia Nervosa Treatment.” Frontiers in psychology vol. 8 2273. 22 Dec. 2017, doi:10.3389/fpsyg.2017.02273