Wednesday, October 3, 2012

The "perfect patient"

Eating disorder treatment presents with a lot of ironies. They are often disorders of perfection, yet treatment sometimes demands perfection to save the person's life. For example, you need to eat exactly this, nothing more, nothing less, to make sure that we can keep you safe and out of the hospital. Ironic, huh? Never mind that the eating disorder is about over-focus on food and weight, yet what must (good) treatment focus on initially? Food and weight. I'm not sure there could be a more ironic field. Well, I guess sometimes in medicine, a similar thing happens. With cancer; here, take this lethal medication in an effort to save your life. Let's kill off all your body's defenses so it can defend itself better. So, I guess it's not just eating disorders, but it certainly is not the norm.

So, if eating disorders are about perfection, and some level of precision is needed at times during the process, what do you do with the "perfect patient?" These are the patients who come in and they want help on some level, but more so, perhaps, they want you to like them, accept them, approve of them. So, they tell you what they think you want to hear. Often times, they actually do the behaviors perfectly. For instance, they follow their meal plan perfectly, but they are not telling you that it is killing them inside. The outcome, in my experience, is that they gain weight, for example, or they stop bingeing and purging, or they stop whatever ED symptom, but the psychological parts of the disorder go unaddressed because they are showing you they are perfect, and are handling things perfectly. They are at high risk of relapse, as a result. And then they can't tell you about the relapse, because a relapse isn't perfect.

On the surface, it sure is nice to have a compliant patient. What a relief, right? Well, not so much. Because eating disorders are terribly painful diseases; they are hell to live with and to overcome. So, the process should not look perfect. Now, in that, I'm not saying that we should expect and accept non-compliance, because that won't help anything either. No, I'm saying that we need compliance, but honesty about horribly painful and difficult that compliance is. That is treatment. That is recovery. If your patient or your loved one is smiling at you about recovery from his/her ED, look deeper. Help him/her to talk about how it really feels to do what needs to be done in order to recover. In doing that, he/she relearns how to talk about all that he/she used her ED to avoid. As the ability to communicate returns, the need for the eating disorder decreases.

That is treatment. That is recovery.


  1. Wow.

    No kidding - just this morning, my current therapist asked me about an admission to a psychiatric hospital when I was a teenager. Among the many things I mentioned was one of the nurses telling me (unsolicited, I add) "You? You'll be back. Because you're too smart and too compliant and that makes them [the rest of the staff] forget why you're here." While that was an absolutely unnecessary evaluation to articulate to me - especially The Evening Before My Discharge - now, nearly ten years on, I can see that the crux of her point was that I would continue to struggle because I put myself below (or above?) the radar.

    Thank you for this post. It's slightly creepy, the topical coincidence, but managed to put a point on something that I was really not wanting to spend time thinking about. Held up a mirror, I guess.

    Take care and thanks again.

  2. Probably one of the most powerful moments in my recovery process was when you (Wendy) told me to break a rule. I had been trying so hard to be the perfect patient and I am SO glad somebody noticed and showed me a better way.

    Something clicked in my brain that day, and I realized I could choose what I did next. I could choose to keep following all the rules. I could choose to break some. I could choose to talk about me. Or not.

    It was a huge paradigm shift. Thinking back on it, it still blows my mind a little. Thanks for that.

  3. This is something that I struggled with in treatment. I was honest, completely honest, I felt, for the first time in my entire life when I went to treatment. But I also tried to be the perfect patient and I was very compliant. Now almost 2 years after discharge, I am still running into this perfect client problem. If I am feeling overwhelmed, or angry, or insecure in my relationship with my therapist, I want to run away until I can get those feelings under wraps before facing her again because I don't want to talk to her about them because chances are I am just being overly sensitive and I have no reason to feel any of those things.
    I don't know how to overcome this problem but recently it has been really taxing on my relationship with my therapist and I just don't know what to do. I am not the perfect patient, in any form of the word and I have hurt our relationship countless times in very destructive ways and it's hard because I so desperately want to be the 'perfect client' and so I filter what I say. But that ends up being so damaging to our relationship as well. It's just a vicious cycle and I'm not quite sure how to pull out of it.

  4. Anon-

    We don't want our patients to be perfect, though I will admit I am at times accused of this! We want patients to be honest; otherwise we cannot help, and to be sarcastic and flippant, we ARE there to help, after all! ;) Therapy is a relationship, so talking about any struggle you are having in the therapy relationship only makes sense, in my opinion.

  5. Jen,

    You are welcome. I hope you are still breaking rules!

  6. Anon-

    That nurse may not win awards for phrasing, but it does sound like she may have hit the nail on the head. I hope you now have yourself at a better place on the radar.