Why do people with eating disorders often not want to get help?

One of the characteristics of eating disorders (EDs) that is quite common and difficult to address is what we call a lack of awareness of the disorder . This refers to the difficulty a person with an ED has in identifying, understanding, and accepting the disorder. This lack of awareness can be total or partial . If it is partial, the person will feel ambivalent about whether or not they have an ED and, therefore, will likely be able to identify the disorder at times and be willing to ask for help, while at other times they will shut down, showing little or no willingness to receive help. All of this is very relevant because, in order to recover from an ED, it is essential to initiate, maintain, and collaborate with the team of professionals who will provide specialized treatment. If the lack of awareness is total, the person, despite suffering greatly because of the disorder, is unable to identify it and will probably not be willing to receive help.

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This lack of awareness of the disorder and its associated consequences often causes a great deal of worry and despair among those closest to the person with the eating disorder: family, friends, partners, etc. They often feel frustration and helplessness when they suspect that their loved one has an eating disorder, but that person becomes irritated when they try to talk about it, refuses to see a doctor, persists in the behaviors characteristic of the eating disorder, and so on.

What can we do when a loved one has an eating disorder but is unable to identify it?

In the case of a minor

When the person is a minor, the legal decision about whether or not they should receive treatment rests with their family or legal guardians. Therefore, even if they refuse help, they will receive it if the adults in their care decide to do so. Despite this guarantee, it is crucial that, whenever possible, the minor voluntarily agrees to treatment, as this is far more beneficial from a therapeutic perspective. It is therefore necessary to treat them with great understanding and affection, while also demonstrating firmness and determination in the fight against eating disorders. We must strive to involve and empower them in the face of the disorder, allowing them to be an active participant in their recovery process, listening more attentively and avoiding overprotective attitudes. Only in very extreme cases where the person may be in an imminent life-threatening situation does the family have the authority to authorize hospitalization to save the life of their son or daughter, regardless of whether they are aware of the disorder.

In the case of a person of legal age

If the person is unwilling to receive help but is not in a life-threatening situation, we must be patient, understanding, and supportive, as our support will be crucial in helping them become aware of the eating disorder. Despite everything, we must be very clear from the outset that we cannot force them to undergo treatment. In fact, it is very important that our support is not aimed at convincing or reasoning with the person experiencing the eating disorder so they understand what is happening to them and go to a doctor. Instead, it is much more effective to focus on supporting them with respect and understanding, without pressure or judgment. Therefore, what will be helpful is that, in this emotionally warm yet firm support, we invite the person to reflect on themselves, with the goal of helping them to independently identify the eating disorder. Forcing treatment would not be the most therapeutically beneficial approach. That is why it is important for the person to be aware of the disorder and be able to be an active part of their own recovery process.

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If we observe or suspect that a person is in a life-threatening situation (severe underweight, altered vital signs, suicide attempts) and, despite attempts to talk and discuss with them the need to go to the hospital to prevent death, they are unwilling to receive medical assistance, we should consider the possibility of involuntary admission. At this point, it is important to remember that involuntary admission should be the last resort and always with the aim of saving the person's life. We must remember that the more involved and aware the person is when undergoing specialized treatment, the greater the likelihood of a positive outcome.

How can a person with an eating disorder become aware of what is happening to them?

There is no definitive answer to this concern, and, as in so many situations, it will depend on each individual case, the specific point the person is at, whether they have undergone previous treatment and what that treatment entailed, their psychosocial support network, whether they have other comorbid disorders, and so on. However, there are two general elements that we can consider when trying to help someone with an eating disorder become aware of their condition:

Going through the cycle of readiness for change

This model, described by James Prochaska, outlines the different phases a person goes through when faced with a dilemma between two seemingly incompatible options , experiencing internal conflict when making a decision. This model is applicable to many situations involving personal dilemmas and has traditionally been used with people who, for example, want to quit smoking (on the one hand, I want to quit, but on the other, my body compels me to continue). It is particularly well-suited to individuals with eating disorders due to the typical ambivalence discussed in the introduction: "I want to overcome the eating disorder, but I don't want to eat," "I want to overcome the eating disorder, but I don't want to gain weight," "I want to overcome the eating disorder, but I don't want treatment," and so on. When supporting these individuals, this model allows us to better tailor our approach.

Traditionally, Prochaska's change cycle model describes 5 phases, which, applied to TCA, are the following:

• Precontemplation : This is the phase in which the person has no awareness of the disorder. They do not identify it and, therefore, it is common for them to attribute their suffering to other factors (my parents don't understand me, the problem is that I'm overweight, etc.). In this phase, there is no ambivalence; the person does not have a dilemma, but rather is almost completely "captive" to the disorder.
• Contemplation : In this phase, as the name suggests, the person considers the possibility of a problem with food and their body. Ambivalence is present at this stage; the person begins to doubt, and from these doubts, they can gradually gain a better understanding of the disorder.
• Determination : In this phase, the person, still ambivalent, is aware of the problem. They may be able to name it, for example, an eating disorder, but will still have difficulty taking action and implementing the necessary steps to address it.
• Action : In this phase, the person will take steps to overcome the eating disorder, such as starting specialized treatment with a clinical team. They will still feel ambivalent and have doubts, but will have enough autonomy to engage with the treatment.
• Maintenance : At this point, the person will feel quite stable and persistently firm in the face of the eating disorder, and this will allow them to become involved in the treatment and, progressively, regain the control that the eating disorder took over their life and well-being.

Having described the phases a person with an eating disorder goes through in terms of awareness of the disorder, it's important to keep in mind that this evolution is usually irregular, constantly progressing and regressing. To understand this, we can imagine the person and the eating disorder are locked in a struggle: sometimes the person is stronger, and other times the eating disorder wins. The goal is to understand this irregular evolution and focus on the ultimate objective, which is for the person to gradually become stronger in the face of the eating disorder and overcome it completely.

Finding motivations stronger than the eating disorder itself

In addition to the phases of change we described earlier, another important element to consider is the motivation (or motivations) the person has to overcome the eating disorder. We often say that you overcome an eating disorder when you have a motivation greater than simply losing weight.

When we talk about motivation, we're referring to milestones that spark interest and enthusiasm in a person. It's important that these achievements are sufficiently stimulating, but also realistic, since in the context of an eating disorder, it's common for the person to be overly demanding of themselves, and what we don't want is to reinforce this behavior. There are many examples of stimulating goals: studying, traveling, making plans with friends, resuming a sport or leisure activity, finding a partner, having children, having a pet... There are as many motivations as there are people; the key is that they are truly stimulating for the person recovering from an eating disorder. These achievements (or desires, dreams, future projects—we can call them whatever we want) will form a significant part of the therapeutic work with the therapeutic team and the support of the family, since the aim of treatment is to recover a normal life that includes all these goals. Without motivation, it will be more difficult to confront the eating disorder. If the person has difficulty feeling motivated by a specific project, the recommendation will be to try to help them find that motivation. Furthermore, we must bear in mind that when a person is depressed and "hijacked" by the obsession with losing weight, finding motivation can be quite a challenge in itself.

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To help the person find motivation, we can ask them questions such as:

• How would you like to see yourself in 5 years? What do you think it will take to achieve it? And to enjoy it?
• You always told me that you would like to (travel, study a certain career, have many children, etc.), does this idea still appeal to you?
• If you're not feeling any particular motivation: Would you like to find something that motivates you? If you'd like, I can help you think about and explore options.

What else will help the person become aware of the eating disorder?

Taking into account everything discussed so far, the cycle of readiness for change, and the importance of feeling motivated by one or more life projects, when facing an eating disorder and feeling the need to overcome it, it is also very important for the person to be able to see what we call the costs of the disorder . We are referring to costs related to everything that the eating disorder prevents the person from doing or, even if they are able to do it, cannot enjoy. Good examples of this are going to the beach, going out to dinner with other people, enjoying a trip, etc.

To help the person identify the costs of the disorder, we can ask them questions such as:

• Do you think there's something you'd like to do that this whole situation (eating disorder) is preventing you from doing? / If this problem (eating disorder) didn't exist, would you do things you're not doing now? If so, what things?
• Are you able to enjoy the things you do? Do you think this problem (the eating disorder) might be making it difficult for you to enjoy things you used to like?
• If you could make this problem (eating disorder) disappear, what would be different in your life?

Last but not least, a message that will be fundamental throughout the recovery process is to convey our unconditional support and the concept that we are a team in the face of the eating disorder , each of us assuming our respective responsibilities, but with great teamwork between the person directly affected, the therapeutic team, and the family. Let us remind her, then, that she is not alone, that she should not face the eating disorder alone, and that together we form the team necessary to overcome it.

Dealing with an eating disorder, whether personally or as a family member, can be difficult and painful. That's why the support and guidance received throughout this process are so valuable. The Association Against Anorexia and Bulimia can help you throughout this process; simply contact us.