Q & A: A Patient Who Doesn’t Want to Get Well

Q: I’ve been treating a 45-year-old woman who has had anorexia nervosa (AN) since her teens. She has been coming to therapy on a regular basis but has not been making much progress. At times she’s not only discouraged, but talks about the fact that she sometimes thinks she really doesn’t even want to get better. She can come up with all sorts of excuses as to why she might prefer to stick with her disorder. Can you shed some light on her situation and on what I might do to help her? (S.B., Cleveland)

A: Unfortunately, psychological attitudes such as those that you’re describing are all too common among adults who’ve had significant AN for a long time. When patients say that they might not actually want to get better, several issues may be present. Some patients may be fearful of what the efforts of recovering and the state of being recovered might require of them. Concurrently, some attribute their lack of progress to their own willful reluctance to recover, rationalizations that provide the comforts of believing that their chronic conditions are fully under their control. In a recently published small qualitative study, Norbo et al. interviewed 36 women about their seeming lack of desire to recover from AN. These investigators found seven core obstacles that the patients identified as interfering with their desire to recover, including perceiving judgments of others, feeling ‘stuck,’ feeling distressed, denial of even having AN, concern about the task of eating, fear of gaining weight, and ‘appreciating the benefits.’ (Norbo et al., Eur Eat Disord Rev. 2011. Feb 9. doi: 10.1002/erv.1097. [Epub ahead of print]).

With regard to what you might do in working with this patient, fully understanding her self-appraisals and mixed motivations is essential. Engaging your patient in the types of discussions that comprise motivational interviewing and non-judgmentally exploring the pros and cons of staying ill and of recovery might help her better reflect on her situation and in turn be willing to come up with and consider new options.

— J.Y.