The Importance of Strong Therapeutic Relationships in Recovery, Ethical Quandaries in the Treatment of Eating Disorders, and an Ode to Professionals in the Eating Disorder Field

Most of the healing I've ever done is not a result of a particular type or style of therapy necessarily (although this is important too), rather it is because of the relationship with the therapist as that is what allows deep and meaningful work in the first place.

A number of studies explore the importance of the therapeutic alliance in an individual's recovery process (both in the context of eating disorders and otherwise). Not surprisingly, there is a lot of evidence to support the benefit of strong therapeutic relationships (NCBI, 2014). 

I have no doubt that eating disorders are a challenging condition to treat because a clinician is often in the circumstance of trying to support someone who is confused about wanting support or, sometimes, quite determined to fight against it. I look back on my own worst moments and (especially in light of working as a nurse now...) greatly appreciate how challenging the role of supporting someone struggling with an eating disorder can be. I still carry a lot of shame around some memories (or the pieces of memory I can recall).

There are a lot of ethical grey areas in treating eating disorders that clinicians must navigate, chief among them, balancing patient autonomy (respecting an individual's free will and right to make their own choices) with the principle of beneficence (supporting outcomes thought to be in a person's best interests). That is not an easy role to occupy or an easy responsibility to have. Patient's with eating disorders are sometimes in mental places where they do not possess a great deal of insight into the gravity of their situation, but at the same time, many patients are fully aware of the potential consequences of their behaviours. The Stanford Encyclopedia of Philosophy has an excellent article on decision-making capacity that looks at the case of eating disorders (specifically anorexia nervosa although I find this discussion to be applicable to other eating disorders as well), breaking it down into five components: 1. understanding, 2. appreciation, 3. reasoning, 4 choice, and finally, 5. values.

The first component, understanding, can be described (in a basic sense) as the ability to comprehend facts. The second component, appreciation, can be described as the ability to grasp the gravity of a situation, the potential outcomes, and the subject's own ability to determine those outcomes. Reasoning (the third component), can be thought of (again in a simplistic sense) as the ability to follow logic. Choice (the fourth component) can be thought of as the ability to indicate and express a decision (e.g. verbally or through writing, etc.) The fifth component (values) is where the impairment of individual's struggling with eating disorders is most often located. Valuing in the context of decision-making capacity can be described as "weighing the risks and benefits of various alternative choices [requiring] values." This is where the decision-making capacity in eating disorders is perhaps most legitimately questioned as eating disorder behaviours and the pursuit of control or thinness are deemed to be "unreasonable" values over life and health, far outside the norm. The weakness in this argument is that who is to say what "normal" values are?

In my worst moments, despite a physically compromised brain struggling to function with limited nutrition, I've still been cognizant enough to be ready to employ the above argument to try and avoid involuntary treatment. Thankfully the health care professionals involved in my own case cared little for having a philosophical argument with an eating disorder, because that's pretty much all I was at that point.

We are a culture that highly prioritizes individual autonomy, but I am quite grateful for the moments my own was taken away from me even if those were very difficult moments that I still struggle with the memory of. In a better place I am able to see that there were people on my side, protecting what they felt were my best interests. I am aware that a decision of that nature would require a great deal of courage to make because it could easily be called into question (or potentially accused of being a decision that violated the principle of "do no harm").

Having control and my ability to choose taken away from me was my worst fear, but it was also something I craved unconsciously. I couldn't allow myself the choice to stop, the professionals in my life took that burden out of my hands. The struggle of having an eating disorder as an adult is that you no longer have your parents to make your choices for you. I hadn't realized how much of a blessing that was when I was younger and only craved the ability to make my own (disordered) choices.

I am eternally grateful for the therapeutic relationships I have had to help support me on my journey because I know not everyone has that chance. It is challenging to build any kind of solid relationship with a therapist or similar kind of clinician who is familiar with eating disorders (assuming one can even manage to afford or gain access to therapy or similar supports in the first place...) I was lucky enough to gain access to services that didn't have an associated fee (the blessing of public health care). The downside of public health care is that there is simply not enough funding to support sufficient services for individuals struggling with eating disorders. There are so many limitations clinicians in the field of eating disorders must work within as they strive to help patients. Besides that, there simply aren't enough clinicians who are sufficiently trained in treating eating disorders (which can sometimes greatly deter patients from seeking any kind of health care for fear of being triggered or judged).

My personal hope is that with Vancouver Island Voices for Eating Disorders (VIVED), we can help to support patients in finding professionals who they can build strong therapeutic alliances with, but my hope is that we can also support professionals in being able to support patients to the best of their abilities because in the end we're all in this together.

- S. Ritchey