The poor motivation of these patients needs to be addressed from the outset of treatment and kept in mind thereafter. There are various ways of enhancing motivation.(22) These include focusing on establishing a sound therapeutic relationship, making it clear that one is working on behalf of the patient and not their relatives or concerned others, accepting the patient's beliefs and values as genuine for her, and adopting an experimental approach in which the therapist and patient together explore the use of different treatment strategies. In addition, it is worthwhile helping the patient review the relative advantages and disadvantages of change. When doing so, it is important to draw a distinction between the short-term and long-term consequences of change since these patients tend to focus on the immediate present rather than the future.
To help motivate the patient, the therapist also needs to identify clinical features that the patient might view as a problem. It is often useful to ask patients to read about anorexia nervosa and its characteristics. Good accounts have been written by Palmer (23> and by Bruch.(24) Initially, many patients are reluctant to accept the diagnosis but once they have read about the disorder most find that they identify with it. It is particularly important to educate them about the physiological and psychological effects of starvation, especially the impaired concentration, preoccupation with food and eating, sleep disturbance, sensitivity to cold, ritualistic eating, and enhanced fullness secondary to delayed gastric emptying. Most patients have these features and once they understand their origin, they are more willing to countenance weight gain. It also needs to be explained how starvation tends to perpetuate the eating disorder.
The issue of motivation is less problematic with those patients who binge eat since the loss of control is almost invariably a source of distress. Nevertheless, they may only be interested in regaining control over eating and not in making changes in other areas.
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