Compassion Versus Coldness in Eating Disorder Treatment:

On Linked-In a therapist asked should an eating disorder therapist be compassionate or “cold and rigid”?

This is a huge question; boundaries are important because they foster trust and engagement; many of our patients lack boundaries and we need to model good boundaries for them. Treatment requires compassion, speaking the language of the eating disorder using "hip pocket patient thinking" to show people we "get them”. But too much compassion may mean that we collude with eating disorder thinking and behaviour so it is not sufficient for recovery to take place, we also need to do some hard work shoulder to shoulder with our people, insist on home assignments and even use "blackmail strategies" such as a 10 minute interview instead of an hour of therapy if a client engages in treatment resistant behaviour. So, sometimes being provocative and challenging too. I once did a 2 hour presentation for an NHS service in the UK on therapist qualities for eating disorder treatment and (only) one of the conclusions is that a sense of humour helps too.

Compassion is important, yet bear in mind that often a client becomes more interested in their relationship with the therapist rather than doing the work because of early attachment problems with their parents or a history of neglect and abuse. This is a vulnerable client group. I don’t think that we can do much unless we have a good relationship which becomes a template for other relationships in a sufferer’s life, which involves learning skills for managing conflict and a good balance between avoidance and dependency.

Psychotherapists have to be on guard against NEEDING to be liked by our patients, and always having to be too kind, which can interfere with their treatment and which puts us at risk of colluding with the eating disorder. This is, I guess, why I am not scared of being controversial and at times making people angry with me.