ABSTRACT
Treatment of the chronically ill demands awareness of the realized "customs" by which these patients insist they must live: without deviating from routines, without contemplation of alternatives or new possibilities. It requires an understanding of why it is hazardous to ask patients with Severe and Enduring Anorexia Nervosa (SE-AN) to challenge their routines too soon, too forcefully. It requires what we believe should properly be seen as the complement to the psychopathology itself: an ability to infer the misery that has pervaded the patient's mental life over many years, to give testimony to the constraints the illness imposes, to accept that the avoidance patterns that mark their life afford no small measure of personal "safety", to understand the trade-offs. Intellect may seem antithetical to the sacred principle of treatment motivation, but asking that a compromise be struck, wanting the patient's grudging cooperation, means that the single most important element needed for successful management of SE-AN is lacking.
