When all else fails, blame the patient

"You just don't want to get better. Why don't you want to get better?"

My therapist (pretty much all of 'em before about 2006) was annoyed with me. I was going to therapy, talking, working on my "issues," and still I wasn't getting any better. I was still batty, still underweight or losing weight, still restricting or purging. I saw a therapist, psychiatrist, dietician, and internist as needed. I was doing everything I was "supposed" to.

And still I was sick. I had all of the proper treatments, with all of the experts, and I was still sick. I certainly blamed myself for my illness (and still sort of do). So why shouldn't my treatment team? It had to have been my fault...right?

Turns out many doctors and psychologists think that way. After all, they're human, too.

Writes Richard Friedman:

[A therapist] had been working with [a man with clinical depression] for nearly three years without significant progress, and she was now doing what many clinicians do when the chips are down: blame the patient for failing to improve.

“I think he has an unconscious desire to remain sick,” she told me.

About a month later, I saw this patient respond remarkably well to a novel treatment. Free of depression at last, he was joyful and relieved — an odd reaction, you must admit, from someone who secretly wished to be ill.

When Friedman questioned the man about the differences between his current state and his depressed state, the man responded "I guess I just think like that when I'm down."

The negative, pessimistic thinking was a result of the depression, not necessarily its cause (at least not totally). So the therapist was, essentially, colluding with this man's illness by saying he didn't want to get better.

And if you don't see the similarities with eating disorders by now, please go snort some espresso grounds and come back once the spots clear from your eyes.

Of course, EDs are a little different. Anorexia in particular is egosyntonic- that is, the sufferer doesn't mind the illness. Furthermore, anorexia tends to be anosognostic and the sufferer doesn't even think they're ill to begin with. Which makes blaming the patient all that much more ironic. How can someone "want" to stay ill if they don't think there's much of a problem in the first place? And what's more, even when illness is recognized, the very illness makes the symptoms more palatable and denies their seriousness.

So maybe lack of progress in treatment doesn't call for blame (of the sufferer, of their parents, of carbon emissions, of this barmy election season), but rather a different approach.

You'd think they would teach this in "therapist school," but the simple matter is that therapists are all too human.

Concludes Friedman:

Chronically ill, treatment-resistant patients can challenge the confidence of therapists themselves, who may be reluctant to question their treatment; it’s easier — and less painful — to view the patient as intentionally or unconsciously resistant...

But a vast majority of patients want to feel better, and for them the burden of illness is painful enough. Let’s keep the blame on the disease, not the patient.

It's true- even the most anosognostic anorexic* is miserable, as much as he or she may deny it. An eating disorder is such a tremendous burden that the sufferer and his or her family don't need any more heaped on top of them in the form of blame.

*Say that three times fast. It's a good test to see if the snort of espresso grounds really worked.


Katy said...

Ahhhh, the concept of "secondary gain" so often harped on in psychology...

"What are you getting out of staying sick? What benefits are there to you to not being well?"

And the stock ED answers, "fed" to you ad nauseum (and if you disagree, you're "in denial," of course): are you trying to avoid growing up? Does it give you an excuse when things don't go well in your life? Are you trying to get attention? Is making your parents worry the only way you know how to get your Mommy & Daddy to show they love you?


Luckily my therapist isn't so into that sort of BS, but I spent FAR too long in an outpatient program, where I swear on my life that had one more inexperienced therapist who barely knew me but was sure that since I had an ED I MUST be the same person she read about in her had textbooks insisted I was avoiding independence (subconsciously, of course), I probably would have socked her.

Anyway...I thought this article was terrific, and it makes me ever more grateful for my persistent psychiatrist, who simply kept tweaking & changing my meds over and over again for nearly three years before we found something that even BEGAN to touch my depression. He never ONCE blamed me or told me I "wasn't trying." It's great to see a doctor acknowledge that sometimes the doc's fear of seeing her/his own impotence/fallibility distorts perception & results in undue blame and pathologizes people who are genuinely ill. Hopefully other docs will read it!

Crimson Wife said...

I've been in recovery for 14 years and BELIEVE ME, I want more than anything else to never have to deal with body image or eating issues ever again. I've got better things to do with my life than worry about food and weight but it's still a real challenge. I have made progress over the years, but there are times when I have setbacks (particularly when I'm post-partum). It's like a chronic disease to be managed rather than something that can be "cured".

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I'm a science writer, a jewelry design artist, a bookworm, a complete geek, and mom to a wonderful kitty. I am also recovering from a decade-plus battle with anorexia nervosa. I believe that complete recovery is possible, and that the first step along that path is full nutrition.

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nour·ish: (v); to sustain with food or nutriment; supply with what is necessary for life, health, and growth; to cherish, foster, keep alive; to strengthen, build up, or promote


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