On December 3^rd, Monte Nido Vice President of Clinical Services Danielle Small, LMFT, CEDS-C and Monte Nido Regional Director of Clinical Operations for the Mid-Atlantic and Southeast Sarah Lewandowski, MA, LPC, CEDS-C presented “Navigating Resistance in Eating Disorder Treatment,” to explore one of the most challenging and often misunderstood elements of eating disorder care.

The discussion offered a nuanced look at readiness, ambivalence, and the many clinical factors that shape engagement in treatment  

Understanding the Function of Resistance to Eating Disorder Treatment

Resistance is often framed as defiance, denial, or lack of motivation. However, resistance frequently serves a protective psychological function. It may signal fear, ambivalence, identity conflict, or unmet emotional needs, not a lack of investment in recovery.

Eating disorders are egosyntonic, meaning the illness can feel aligned with the client’s core identity. As a result, clients may genuinely perceive the eating disorder as helpful or protective, even in the face of medical challenges. This makes resistance a natural part of care rather than a barrier clinicians must push through.  

Understanding the purpose of resistance opens the door to empathy, alliance, and more effective intervention.

Readiness vs. Resistance: A Critical Distinction

The session highlighted the importance of differentiating ambivalence from resistance in eating disorder treatment. Clients in the contemplation or preparation stages of change may express appropriate goals but struggle to translate them into behavior, often due to underlying fears such as fear of weight gain or cognitive distortions.

Two guiding clinical questions were offered:

• Is the client unable or unwilling to change right now?

• What fears are blocking change?

Recognizing that ambivalence is not defiance helps recalibrate treatment expectations and reduces unproductive power struggles  

Evidence-Based Approaches that Address Ambivalence in Eating Disorder Recovery

Many modalities used in eating disorder treatment explicitly incorporate strategies for working with resistance and supporting readiness for change.

This webinar reviewed several, including:

• CBT: CBT-AN, CBT-BN, CBT-E, CBT-AR, which emphasize eating stabilization, cognitive restructuring, and forward-oriented planning

• Family-Based Treatment (FBT and FBT-TAY), which uses an agnostic illness model centered on parental leadership

• Adolescent-Focused Therapy (AFT), which targets identity, individuation, and ambivalence when parental involvement is limited

• Adjunctive trauma and somatic modalities, such as CPT, EMDR, SE, ART, and TBT-S

Successful implementation requires fidelity to the model, thoughtful assessment of maintaining factors, and careful alignment between the client’s stage of motivation and treatment expectations  

Common Presentations of Clinical Resistance

There are several ways resistance shows up in eating disorder treatment:

• Pseudo-compliance: the client appears to follow treatment while secretly restricting or compensating outside of session

• Active defiance: verbal protest while performing required behaviors such as “Fine, I will eat it but I hate it”

• Tug-of-war dynamics: power struggles between the healthy self, the eating disorder self, and the treatment team

• Hidden compensatory behaviors that undermine visible progress

• Reassurance-seeking questions that reinforce eating disorder-driven thinking such as “Do I look smaller?”

Notably, when clinicians become entrenched in these dynamics, the eating disorder gains power. Understanding the function of these patterns allows teams to respond with curiosity rather than confrontation  

Resistance to Treatment in Adolescents: Unique Dynamics

Adolescents bring their own developmental complexities to treatment. These may include:

• Parent and child misalignment: caregivers may resist higher care recommendations while adolescents resist surrendering control

• Autonomy development: typical teen individuation can be mistaken for or masked by eating disorder-driven resistance

• School demands: academic pressure, mealtime supervision challenges, and medical accommodations require careful coordination

• The “healthy weight paradox”: symptoms may persist even when weight appears “normal,” which requires a shift toward symptom-focused interventions

These dynamics reinforce the need for strong family involvement, clear communication, and education on symptom-driven and not weight-driven assessment.  

Comorbidities and Their Influence on Ambivalence

Resistance to eating disorder treatment is often intertwined with other diagnoses, including:

• OCD: where compulsions provide short-term relief, making eating disorder behaviors feel preferable

• Borderline Personality Disorder: characterized by identity confusion, splitting, and emotional volatility

• Substance use disorders: where symptom swapping and shame complicate motivation

• Autism and ADHD: where sensory issues, rigidity, overwhelm, and interoception difficulties affect engagement

• PDA and demand avoidance: which involve resistance to both internal and external demands

• Selective mutism: where silence becomes a powerful form of avoidance

Recognizing these patterns helps clinicians tailor interventions and avoid mislabeling neurodivergent traits or trauma responses as noncompliance  

Trauma, Avoidance, and Sequencing of Care

It is important to recognize that PTSD and eating disorders frequently reinforce one another. Avoidance is a shared symptom of both, and eating disorder behaviors can temporarily numb distress, making ambivalence about giving them up highly predictable.

Key points included:

• Clients with PTSD and eating disorders often experience more complex illness courses and higher distress

• Trauma and eating disorder treatment should be addressed concurrently rather than sequentially

• Delaying trauma work can inadvertently communicate that clients are too fragile to engage in their own healing

Reduction in PTSD symptoms is often associated with reductions in eating disorder symptoms, highlighting the interdependence of both treatment pathways  

Medical, Psychiatric, and Pharmacological Resistance

Clinicians frequently encounter resistance to eating disorder treatment shaped by medical history, weight stigma, and fears around medication. Topics covered included:

• Navigating care for clients with a history of bariatric surgery or GLP-1 use

• Addressing concerns about weight gain from psychiatric medications

• Supporting medically unstable clients who decline higher care recommendations

• Distinguishing between eating disorder-driven behaviors and genuine medical conditions

There is an emphasis on leading with empathy, validating weight-related fears shaped by a biased culture, and engaging multidisciplinary teams to maintain safety and trust.

Clinician Burnout and Countertransference

Resistance does not belong solely to clients. Clinicians can experience their own resistance, often shaped by burnout, over-identification, or the emotional toll of feeling responsible for fixing treatment outcomes.

Important reminders included:

• Distinguishing clinical stagnation from client resistance

• Monitoring countertransference that may lead to avoidant or overly controlling interventions

• Prioritizing self-care, supervision, and boundaries to maintain sustainability in this work

Reframing resistance as a phase of treatment and not a failure supports resilience across the care team as well as the client  

Caregiver Resistance and Family Misalignment

Caregiver dynamics significantly shape eating disorder treatment outcomes. This presentation highlighted patterns such as:

• One parent minimizing symptoms while the other advocates for treatment

• Discomfort with weight restoration

• Parental eating disorder behaviors interfering with recovery

• Stigma-based avoidance

Family work is foundational and not optional, and early, direct intervention with caregivers can prevent entrenched misalignment that derails progress  

Body Image, Weight Stigma, and “Healthy Eating” Narratives

Resistance to eating disorder treatment is often fueled by internalized weight stigma and cultural messages that equate health with rigid control.

Key points included:

• Exploring clients’ values and the expectations shaping them

• Challenging shame and fear of weight uncertainty

• Educating clients that restored menses or hair regrowth does not necessarily signal full weight restoration

• Examining what “healthy eating” truly means beyond socially prescribed restrictions

These conversations help clients build resilience in a world where appearance-based messaging is pervasive and often harmful.  

System Barriers and Access to Eating Disorder Care

Resistance is not always psychological. Often, it is structural. The presenters acknowledged challenges such as:

• Limited insurance coverage

• High costs of care

• Provider training gaps

• Geographic barriers

Clinicians can support clients by offering clear documentation for insurance, advocating for equitable access, and helping families navigate limited resources without shame or blame  

Relapse, Recidivism, and Post-Treatment Resistance

Recovery is nonlinear, and returning to treatment is not a failure but a natural part of long-term healing. Themes included:

• Recognizing environmental triggers that reignite resistance

• Normalizing repeated admissions as opportunities for new layers of work such as the onion metaphor

• Supporting clients who feel torn between wanting recovery and wanting the temporary relief of the eating disorder

This “50 50 life” phase reflects ambivalence and not failure, and requires compassion, patience, and steady clinical guidance  

Understanding Resistance as Communication in Eating Disorder Treatment

This Ask the Experts session offered a deeply validating lens: resistance is communication, not obstruction. By exploring its roots, including developmental, psychological, medical, familial, and systemic factors, providers can better tailor their interventions, strengthen therapeutic alliance, and help clients move toward meaningful change.

Monte Nido remains committed to supporting clinicians with evidence-based education, collaborative discussion, and a treatment philosophy grounded in compassion for every body.