Can methods that focus on eating behaviour and individual agency improve success rates in eating disorder recovery?

Success rates in eating disorder treatments are disappointing, and many calls have been made in recent research literature for innovative approaches to improve outcomes. This Comment article offers an argument for the importance of behaviour and agency in supporting eating disorder recovery, where behaviour encompasses eating and other everyday actions and habits and agency is an individual's capacity to set priorities and intentions, generate insights, draw conclusions, make decisions, and perform actions. Current treatments often deprioritize eating and other behaviours as well as individual agency for the patient/client, with lower importance often attributed to behavioural change than to physiological or psychological change. Reasons for deprioritizing behaviour may include beliefs about the therapeutic alliance, the intellectual appeal of psychological exploration, and the ready measurability of physiological factors. Reasons for deprioritizing personal agency may relate to an only partial shift away from the paternalistic model of medicine, influenced by the physical severity of EDs and by gender dynamics between clinician and client/patient. Drawing on principles and practices from solution-focused coaching and solution-focused brief therapy, we argue that low-agency forms of healthcare are likely to perform poorly in general, given the problematic effects that typically result from the giving and following of advice. Low-agency and low-behaviour approaches are also likely to work poorly for EDs in particular, thanks to both the centrality of eating behaviours and the fact that EDs are often experienced as initially egosyntonic exercises of personal agency. We describe how a high-agency-high-behaviour model of ED treatment could help improve recovery rates by scaffolding a process of progressive empowerment in which the affected individual identifies how personal agency has been lost in the experience of their ED and decides whether, why, and how they wish to reassert it. We survey existing applications of solution-focused methods in the ED domain and suggest ways of testing the proposed ideas. We conclude by sketching broader ways for the field to continue its evolution towards higher-behaviour and higher-agency methods, as part of a general shift to forms of healthcare that are truly responsive to the individual and firmly grounded in the realities of practical change.