Ambivalence Toward Eating Disorder Treatment: 6 Ways to Help Patients and Families
By Kyle Hardner
Seven years ago, Martha Danielson (she/her/hers) began seeing signs that her daughter Lydia (she/her/hers), then 14, might be developing an eating disorder. “She was concerned about calories and her weight,” Martha says. “She went from being a very social kid to being very isolated.” Lydia was diagnosed with anorexia soon after.
Martha and her family tried to care for her at home, but Lydia quickly reached a point where she needed a higher level of care. Still, Martha had doubts about agreeing to more intensive treatment. “Lydia was in her sophomore year of high school,” Martha says. “We worried she wouldn't be able to participate in extracurricular activities.”
These conflicting feelings are known as treatment ambivalence, and they're quite common among patients and their families and caregivers navigating mental health treatment.
What is ambivalence?
“Ambivalence is like a tug of war,” says Elizabeth Easton, PsyD, CEDS (she/her/hers), national director of psychotherapy at Eating Recovery Center and Pathlight Mood & Anxiety Center (ERC Pathlight). “Part of them knows they need support and that their current treatment methods aren't working; yet another part is fearful about what they stand to lose or miss out on while in treatment.”
Feelings of ambivalence are quite common and can happen at multiple points throughout a person's mental health journey. “Ambivalence is a universal response humans experience as they process major changes in their lives,” Dr. Easton says. Let's look at some common examples of ambivalence seen by our treatment experts.
Root causes of ambivalence
Often, patients and caregivers—like Lydia and her family—experience ambivalence due to the time-intensive nature of treatment.
“People worry that they have to put their school, work, family and friends on pause,” says Maggie Moore, MA, LMFT (she/her/hers), national family outreach manager at ERC Pathlight.
Other times, patients struggle with feelings of hopelessness and think that treatment won't actually help them get better, or even worry about the change that will come if it does.
Another common barrier is the fear of the unknown. “Concerns about not knowing the clinical team and people you'll be in treatment with when you're going through a mental health crisis are understandably one of the most uncomfortable parts of the treatment process,” Dr. Easton says.
And while ambivalence can happen with any mental health disorder, we tend to see it occur in people with eating disorders in particular. “That's because many patients believe their eating disorder is working for them—that it's helping them look or feel a certain way—when in reality it's causing them to lose friendships and sometimes lose jobs,” says Dr. Easton.
For families and caregivers, shame and self-blame are two common causes of ambivalence. “It's hard for some to acknowledge that they aren't equipped to support their loved one in the way that person needs to be supported,” Moore says. They might also feel conflicted about how to explain a loved one's treatment to their extended family and friends, or the time commitment and other logistics involved. It's helpful to lay out all treatment options from the beginning, including virtual care which can help their loved one build resilience and skills from the comfort of home.
6 ways to guide your clients and families
While some providers may view ambivalence as a barrier to care, in reality, the opposite is true.
“The points where people get the most stuck in life are the places where the greatest opportunity for growth and healing exists,” Dr. Easton says.
Here are six ways to guide patients and their families and caregivers through ambivalence.
1. Validate patients' feelings.
Ask patients to explain the reasons they feel ambivalent, and listen with equal parts curiosity, compassion and humility. “Understand that the version of themselves that is in crisis feels incredibly vulnerable and has a lot of self-doubt and fear,” says Dr. Easton.
2. Explore their perspective.
“Use motivational interviewing to create allegiance and alliance,” Moore says. For example, ask patients what they stand to lose by entering a higher level of care, which can range from daily independence to missing out on special events and family vacations. Then explore what they stand to gain.
3. Stand firm in your recommendation.
Reinforce your clinical recommendations, but don't push patients into treatment. “Walk with your patient, not ahead of them,” Moore says. “Give patients the clinical perspective behind your recommendations and why you believe they can do this.” The sooner they get the treatment they need, the better opportunity they have for long-lasting success in recovery.
4. Meet with families and caregivers separately from patients.
Take extra time with families and caregivers, recognizing that they are often a few steps behind their loved one in understanding why a certain level of care is needed. “Ask about their fears and give them time and space to ask questions,” Dr. Easton says.
5. Find a program that integrates families and caregivers into treatment.
One common reason for ambivalence is the fear that they will be shut out of their loved one's path forward, or that they will be blamed in some way. Instead, programs like those offered by ERC Pathlight make family and caregivers an integral part of treatment, providing education and family programming so they can learn and heal alongside their loved one.
6. Recommend a support group.
Support groups offer a small community where your patients and their families and caregivers can share their mixed feelings in a safe space with peers who have similar experiences, building their confidence and hope for recovery.
Check out our free ERC Pathlight support groups online.
When ambivalence leads to resistance
If a patient starts ignoring sessions or failing to follow through with treatment plans—they've crossed over from ambivalence to resistance. This can create challenges but also opportunities for providers who take the time to explore the reasons behind the resistance.
“When providers are willing to sit in resistance, explore it and not push patients out of it, it can lead patients and caregivers, and even providers, to beautiful places of growth,” Dr. Easton says.
For Martha, navigating through her ambivalence helped her daughter get the treatment she needed. Today, Lydia is thriving, and Martha is glad she sought a higher level of care for her. “No parent is ready to do this, but when a medical or mental health issue comes up, you have to put your trust in the professionals,” Martha says. “Everyone we met at ERC Pathlight eased our fears. They saved Lydia's life and gave us our daughter back.”
View Common FAQs for Your Patients
Download and share this free resource with your patients and their families, addressing their logistical questions and common roadblocks to accessing treatment.
View Our Free On-Demand Ce Course
To learn more about navigating ambivalence, scan the code to access “Addressing Ambivalence for Treatment and Recovery in Young Adults” and earn 1.5 CE hours. To access this course, scan the code, enter your information and use the code Magazine 23.
Find a Free Community Support Groups
Your patients can access more than 20 free weekly support groups, providing peer support, education and connection as they navigate any mixed feelings in a safe space. To register, visit www.EatingRecovery.com/Support-Groups or www.PathlightBH.com/Support-Group.
This article first appeared in Luminary, A Magazine for Mental Health Professionals. Find more articles for additional tips, resources and insights from leading experts in the field.
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