Anorexia nervosa is a complex illness, like most illnesses that involve the brain. There is a wide spectrum of severity, ranging from cases that easily turn around with re-feeding and seem to disappear for good, to those that are  crippling and debilitating for an entire life.

I think it goes without saying that neither the patient nor their family are to blame for which form the patient has been afflicted with (mild, moderate, severe, chronic disabling)-- but in case there are a few readers out there for whom this is new: they are not to blame!

Because the spectrum of severity of illness is broad, the expected results that can be obtained with good treatment are not uniform. And I mention this because understanding that not everyone will reach “full psychological and physical recovery” within months will help avoid the trap of assigning blame for failure to do so.

Over the years I have heard just about every form of blaming.

Blaming the sufferer: “Why isn’t she/he motivated to recover? Don’t they understand how this is ruining everyone’s life, including their own?” and “Why can’t she get it?” (usually said by a parent or other family member in frustration). Or, voiced by a professional: “She/he is not a candidate for insight.” If a young person is truly “not a candidate for insight,” meaning that their anosognosia is too severe or they are too immature still, that can hardly been seen as a choice.

Blaming the family: “They just won't follow through on our recommendations” or “The mother has an eating disorder herself!”

Blaming the provider: “Obviously they are not able to cure her body image distress, we’d better find someone who can,” or “Why can’t they change his mind/convince him that this is harmful?” or “That doctor/therapist just can’t seem to convince her to give up her eating disorder.”

Experience has shown that physiological goals are the easiest to achieve. Whether you are doing home re-feeding or are being re-fed in a program like ours, it is reasonable to expect complete weight restoration. In fact, it is critical. Return to regular menses (where appropriate) should also be achievable. Bones can repair. Hair can regrow. Temperature can normalize, energy return and the smile come back.

But psychological goals are more difficult to achieve. And the circular firing squad of blame is not going to help. Many children and adolescents will be able to find psychological peace with weight gain, some will not. It does not mean that they shouldn't be required to (re)gain weight, it just means that neither they, nor their family nor their treatment team should be blamed for the fact that they remain tortured by thoughts they cannot control. All the talking in the world by the “right” therapist or doctor will not “change their mind.” Brain healing must take place, and that can take time. Sometimes, all you can do is hold a child in steady physical remission (otherwise known as weight restoration) and let their brain mature and grow. Then, perhaps, they can have time to develop insight and re-pattern their own responses to anxiety.

We are not always going to get complete recovery, and to look around for someone to blame when it doesn’t happen will only force you down a path of endless rounds of treatment and constant dissatisfaction with yourselves, your child and your treatment team. Full physiological recovery: yes. Full psychological recovery: maybe. The old-fashioned physician's “tincture of time” may be the necessary ingredient to final success and to healing where it can occur.

And when you see someone with anorexia nervosa who is still tortured by their thoughts and can't seem to “change their mind” or demonstrate insight, be grateful that you may have had a different experience, but be humbled by the thought that your child had the good fortune to be afflicted with a more mild form of the illness. Again, there but for the grace of God go I.