Is Residential Treatment Safe to the Detriment of Becoming a Revolving Door?
By Alexis Strauss, MS (in progress)
It has been months, maybe even years, one appointment after another—psychiatrist, psychologist, nutritionist, occupational support staff, ED coach—repeat, week after week. As a support to someone who struggles with an eating disorder, you may feel a combination of hopeless or helpless, intermixed with sparks of optimism, yet quickly smothered as small changes prove ephemeral.
Finally, the individual struggling decides they are motivated to enter a higher level of care at a residential facility. You wonder if this is a spark that will sustain a pathway of recovery. However, it is well known amongst clinicians that doorways to residential facilities are often revolving and motivation for treatment can be associated with poor prognosis. Is this desire to enter a residential facility a reason to anticipate sustainable change; or is it merely a reflection of their own frustration and hopelessness, an additive part of the repetitive treatment cycle? Unlike dysfunctional thought patterns in individuals who struggle with eating disorders, motivation is rarely dichotomous. However, whether motivation is an addition to a cycle or a reason to anticipate sustainable change, the fact that the individual struggling is attempting something different is important to note.
In most situations, motivation is generally associated with better outcomes. As humans we experience this in our jobs, relationships, and even hobbies. The more motivated we are to engage in a task, the more we tend to persevere and obtain successful outcomes. However, it is important to distinguish motivation for treatment as motivation to change or motivation to enter treatment for other reasons. Further teasing apart the implicit desires for treatment can be important in not only understanding an individual’s needs, but also in directing treatment goals.
If an individual is motived to enter treatment because they are motivated to change, this is relatively intuitive; they will likely engage proactively in treatment, resulting in a better prognosis in comparison to someone who is not motivated to change.1,2 Yet even if an individual is motivated to change, fluctuations in this motivation are the norm rather than the exception,3 and other motivations for treatment may undergird continued engagement. One of the most profound secondary benefits of residential treatment is the provision of an emotionally, physically, and psychologically safe environment; which can be inherently rewarding, particularly if this safety is subpar in an individual’s home environment.
As relational creatures, the relational attachments that are primary in our lives become the sources for a safe environment. Attachments are relational ties that develop and form over time between an individual and an attachment figure.4 Ideally, these attachment figures are able to ensure the functions of a healthy attachment known as safe haven and secure base functions. In layman’s terms, this means when an individual is distressed their attachment figure is able to effectively provide comfort and support, a safe haven. Additionally, this attachment figure also serves as a reference point to provide guidance and protection during exploration of goals and challenges, a secure base. When an attachment figure is able to consistently provide both of these functions, the attachment is said to be secure. 5
Women who struggle with eating disorders have fewer normative secure attachments than women in the general population, meaning fewer opportunities for psychological and emotional safety/security. In comparison to the general population, where approximately 30 percent of individuals develop insecure attachments, this percentage is over twice as large, between 70 and 100 percent, for individuals who subsequently struggle with eating disorders.6,7 In sum, this means that eating disorder sufferers are often lacking in environments which provide functions of emotional/psychological safety and security. Some researchers have proposed that an eating disorder in and of itself can function as a pseudo attachment, providing functions of a safe haven8 (consistent comfort when distressed). Entering into treatment as an implicit source to fulfill these deficits can be very motivating, especially when an individual begins to experience physical and mental costs which hinder the effectiveness of an eating disorder fulfilling these functions.
In consideration of attachment deficits, clinicians should critically examine complexities of motivation, which like eating disorders themselves, are not so black and white. The first step in gaining a full understanding of motivation for treatment is acknowledging its complexities and recognizing it will likely fluctuate and could also be signifying something other than, or in addition to, a motivation to change maladaptive behaviors. That being said, if motivation, on some level, to enter treatment is driven by needs for psychological safety and security, then treatment goals should address transitioning these secondary benefits to sources other than treatment. Exploring alternative sources of attachment, such as spiritual attachments, peer groups, pets, or alternative relationships may be an important goal in creating a safe environment. Developing psychological/emotional safety and security external to treatment is imperative as an individual relinquishes their maladaptive coping mechanisms alongside the unsustainable attachment benefits provided in residential treatment. Ideally, motivation to enter and remain in residential treatment will then transition away from a motivation to obtain these secondary attachment benefits and toward a motivation for sustainable change.
About the author:
Alexis Strauss, MS (in progress), works as an eating disorder coach in the Philadelphia region. Her extensive experience working with patients in clinical and research settings informs her current research interests, focusing on the interplay between attachment and intrapersonal variables (motivation, hope, identity) in relationship to ED outcomes.
- Hoetzel, K., von Brachel, R., Schlossmacher, L., & Vocksm, S. (2013). Assessing motivation to change in eating disorders: a systematic review. Journal of eating disorders, 1, 38-47.
- Mansour, S., Bruce, K., Stieger, H., Zuroff, D., Horowitz, S., Zuroff, D., Horowitx, S., Anestin, A., & Sycz, L. (2012). Autonomous motivation: A predictor of treatment outcome in bulimia-spectrum eating disorders. European Eating Disorders Review, 20, 116-122.
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- Ainsworth, M., & Bell, S. (1970). Attachment, exploration, and separation: Illustrated by the behaviour of one-year-olds in a strange situation. Child Development, 41, 49-67.
- Bowlby, J. (1969). Attachment and loss: Vol 1. Attachment (2nd). New York: Basic Books.
- Lunn, S., Poulsen, S, & Daniel, S. (2012). Subtypes in bulimia nervosa: The role of eating disorder symptomatology, negative affect, and interpersonal functioning. Comprehensive Psychiatry, 53, 1078–1087.
- Ringer F., & Crittenden P.M. (2007). Eating disorders and attachment: The effects of hidden processes on eating disorders. European Eating Disorders Review, 15, 119–130.
- Henderson, Z., Fox, J., Trayner, P., & Wittkowski, A. (2019). Emotional development in eating disorders: A qualitative meta-synthesis.Clinical Psychology & Psychotherapy, 26, 440-457.