Barriers of ambivalence and motivation
There are multiple psychological reasons why people
with AN may be reluctant to present for assessment or
are guarded during an assessment. The disorder itself, at
best, presents genuine ambiguity for many who suffer
from it. As one woman described it, “I want to get rid of
the disorder but not the body shape (of AN)…I want the
best of both worlds” [17], page 29. AN has been demonstrated
to serve more pivotal functions of affect numbing
or identity and the individual may see no reason to alter
it at all or, as is most common, the patient may move
between wanting to address it and not seeing it as a
problem. This ambivalence is complex and may shift
even in the preliminary assessment interview. The interview
may be infused with ‘bargaining points’ or requests
for ‘conditional’ or no treatment at all. With these dynamics
at play, careful clinical skills are required. It is important
that such bargaining is not seen as ‘manipulation’ with
the negative connotations of that concept. Rather, it
represents a genuine struggle with symptoms that are
both controlling and out of control, and at times deeply
confusing for the person. It can be very validating to the
client, and move the process of assessment along
smoothly, to express understanding for the two seemingly
opposite positions that can be held within the one
person, and to not dismiss or invalidate the part of the
client that wants to retain the illness. Family and carers
may be equally conflicted about the need for treatment,
with parents sometimes caught between loyalty for their
offspring and wanting to heed professional advice.
Assessment of family functioning is discussed later in this paper.