The
Health Professional’s Unique Use of Self
in Treating an Eating Disorder
Excerpted from
Doing
What Works -
The Professionals’ Guide to
Treating Eating Disorders
North American Serial Rights 2006
All Rights Reserved
By Abigail H. Natenshon MA, LCSW, GCF
Up against
it: Coming Cheek to Jowl with an Eating
Disorder
Highly variable in their presentation
from case to case and unique in their
requirements for treatment, eating
disorders present enormous personal and
professional challenges for
practitioners. The vast majority of
highly professional, competent and
well-intentioned health professionals,
when treating these diseases, find
themselves untrained, inadequately
prepared, misguided or otherwise ill
equipped to handle the challenge.
Professionals treating eating disorders
historically have had precious few
places to formally acquire the tools and
techniques of this specialized work.
For those practitioners who schooled
prior to the dawn of an awakening
awareness to these diseases in the
1970’s, there was virtually no
information available. Curriculums
within professional graduate schools
today fail to include the treatment of
eating disorders due to the widespread
misconception that these diseases can be
eradicated simply by treating the
emotional issues underlying and driving
them.
Unequipped to handle the unique
requirements of eating disorder
treatment, practitioners reach into
their own emotional and cognitive
coffers in search of personal and
professional resources to fulfill this
task…an excellent place to begin, in
fact, as an intelligent awareness and
sensitive use of the self is an
essential component in successful eating
disorder treatment. However, because of
the complexity of these diseases, their
counterintuitive and irrational nature,
and their far-reaching and global
effects on the function of individuals
and families, relying solely on
intuition, personal assumptions about
eating disorders, and biases about
dysfunctional eating and weight
management becomes an all too random and
inconsistent process. The vast majority
of people suffering with eating
disorders do not avail themselves of
mental health care, and when they do,
too many slip through the cracks of
diagnosis and quality care.
By their nature counterintuitive, these
disorders challenge commonly held belief
systems and turn typical expectations on
them ear. These diseases invariably feel
better to the patient than does the
process of becoming well; anorexics
do eat…many eat regularly and
frequently… and they typically do not
appear to be noticeably thin or
emaciated; eating disorders do not show
up in doctors offices, and blood, lab
and heart testing for actively eating
disordered individuals generally show
normal results, inciting victims to work
harder at becoming better anorexics;
because eating disordered behaviors
generally occur on the continuum of
normal human behavior, they may appear
to represent a healthy lifestyle and an
enviable display of self-discipline.
Eating disorders are unique among the
mental health illnesses. Setting them
apart is their level of lethality, the
comprehensive nature of the personal and
interpersonal havoc they wreak, the
variety and relative health of the
personality types that contract these
diseases, as well as in the variable
quality of input from the patient’s
familial support system. Practitioners
need to fully comprehend the nature of
these diseases, the depth and breadth of
their implications on all aspects of the
victim’s emotional, social, physical and
personality development and ultimately
on quality of life. Treatment
requires a fully unique approach to
patients, problems, and process, a
uniquely versatile style of practice and
use of the practitioner’s self within
the context of the therapeutic
relationship, along with a
specialized set of treatment protocols
and exquisitely honed techniques and
communication skills. Much like the
patients they treat, in navigating the
choppy seas of eating disorder
diagnosis, treatment and recovery,
health professionals, like their
patients, must learn to develop a high
level of tolerance for functioning
within a realm of the unknown, of
ambiguity, ephemera and the
unpredictable. Be aware that the
process of treating these diseases at
times will feel as out of control for
the practitioner as it does for the
recovering eating disorder patient.
Eating disorders are “big picture”
diseases, making their presence known
through dysfunctions within every life
sphere. Eating disorders affect
physical, nutritional, behavioral,
emotional, cognitive, and social aspects
of the self, leaving no sphere of life
untouched. If eating disorders are
“big picture” diseases, eating disorder
practitioners must become “big
picture” responders. Global diseases
require therapists to be knowledgeable,
inclusive, multi-tasking and versatile
as communicators. For eating disorder
therapists, assessments are far-reaching
and global; responses must be
equally as far-reaching, and at the same
time definitive, integrative, and
linear. Perhaps the most pivotal and
challenging criteria for successful
practice is the practitioner’s wide-lens
integrationist perspective and the
willingness to act on this expansive
vision, not only in viewing this
multi-faceted problem, but in
considering varied and eclectic options
for healing, seeking out and discovering
resources to tap, and thinking and
working “outside the proverbial box.”
This does not come easily for all
professionals, but is essentially what
it takes to do what works.
One of the elements that most clearly
sets the treatment of these diseases
apart from that of other mental health
illnesses is that all elements of
the patient’s system of need must be
recognized and addressed at once,
simultaneously, even while
prioritizing the hierarchy of needs. No
singular element of an eating disorder…
neither the dysfunctional behaviors, nor
the emotional underpinnings that drive
these diseases…can be treated
exclusively. Talking the
multi-disciplinary talk and wearing many
professional hats at once, each
professional in the therapy team becomes
a representative of the healing process,
a coach and counsel capable of
addressing every sphere of concern.
Psychotherapists need to develop a
fluent, working knowledge of the
function and discourse of the medical
doctor and nutritionist ands vice versa.
These diseases resist compartmentalized,
as does their treatment. As issues
arise, they must be recognized,
validated, dealt with, processed, and
resolved, with informed and active
practitioners either advising and/or
referring back to the appropriate
collaborating team member where
necessary.
A maelstrom of forces drives the eating
disorder; the eating disorder ultimately
becomes a maelstrom of forces driving
its victims and their behaviors. Either
the therapist displaces the eating
disorder as a riveting force driving
patient and process in a direction of
wellness, or the evolving eating
disorder can be counted on to pick up
the slack, steering the process and the
individuals embroiled in it in the
opposite direction.
The disorder takes up residence within
the core of the afflicted individual,
captaining the host ship from her very
center, usurping her voice as well as
her judgment. An active, directive,
authoritative (though not authoritarian)
practitioner becomes the new vortex of
stability, anchoring both treatment
process and patient function, providing
focus, direction, and momentum for
patient and family. As optimist and
integrationist, it is for the therapist
to sustain a vision of the patient’s
strengths and to reinforce patient
assets, perceiving the urgent immediacy
of short-term goals, activities and
requirements even while tenaciously
holding onto the vision of recovery that
might be months, years or decades away.
In diagnosing an eating disorder,
therapists need expansive peripheral
vision to see beyond the obvious to
the elusive; reading between the lines,
connecting the dots to see what may not
yet have become fully evolved or clearly
visible. Highly variable in their
origins, triggers, and symptom
presentation, eating disorders present
an exquisitely challenging diagnostic
process. Typically, patients fail to
disclose symptoms, offer evidence of a
partial constellation of symptoms, or
envision symptoms as aspects of normal
living, occurring as they do along the
continuum of normal human behavior.
(After all, who doesn’t overeat or under
eat at times?) Symptoms are typically
seen as indicators of a conscientious
commitment to a healthy lifestyle, and
viewed as assets, not liabilities. Even
the diagnostic DSMIII mental health
“bible” cannot be counted on as the
definitive last word in an assessment of
disorders where symptoms indicating
disease are typically sketchy,
ambiguous, diverse and variable in their
appearance and effect on life function,
both within, and between, cases.
Because more than 50 percent of cases
fall onto the non-specified category of
“Ednos” (eating disorders not otherwise
specified), at best evaluators are left
to rely upon their own generally scanty
knowledge and experience of these
disorders, on their interviewing skills,
and on deduction and intuition in
arriving at diagnoses which are too
frequently missed. It is for you,
the therapist to connect the diagnostic
dots that may do nothing more at the
time of evaluation than approximate the
existence of a clinical eating disorder.
Effective evaluations for eating
disorders are more than diagnostic
inquiries. They are opportunities for
therapists to educate patient and
family, to inspire trust in the
therapist and therapy process, and hope
in the potential for positive outcomes,
to offer a concrete, workable,
step-by-step plan of action, including
referrals to other specializing health
professionals, and provide an open forum
for asking questions and discovering
answers and for involving families
constructively.
Abraham Maslow’s guide to the hierarchy
of human needs speaks directly to the
evaluating practitioner’s requirement to
assess and respond immediately to the
needs of their patients in a sequence
designed first to save lives, second to
attend to life quality. In laying
out an initial plan of action, the order
of priority spotlights first the need
for medical stabilization; second,
emotional stabilization through referral
to higher levels of care to inpatient
units in cases where instability could
result in physical self-harm; third,
re-feeding bodies and brains so as to
facilitate receptivity to the
therapeutic process and the creation of
an environment conducive to the use of
medication. Lastly, education and
support rectifies distorted attitudes
and cognitive belief systems, in the
interest of creating and enhancing a
learning environment that fosters
healing.
Working with these diseases typically
gives rise to emotionally charged issues
that demand clear and constant
self-monitoring. The practitioner’s
own attitudes, personal biases, and
capacity for self awareness and
self-growth all factor significantly
into effective observation, deduction
and response. For the vast numbers
of therapists who have recovered from
their own eating disorder, any issues
that remain unresolved or that represent
emotional vulnerability can intercept
and sabotage effective responsiveness. A
practitioner’s clouded self-appraisal
leads to a lack of the resiliency,
creativity, and intention, to an
inflexible and uninformed use of the
self, ironically mimicking the quality
of function of the eating disordered
patient. Such issues may concern
attitudes about eating lifestyles,
personal weight management and body
image, limit-setting and confrontation,
handling resistance, dealing with the
pervasive ambivalence that defines the
treatment and recovery processes, the
therapist’s response to recidivism, and
integrating parents and families as
child and treatment advocates.
As we eat, so we live. Dysfunctional
eating and weight management are a
metaphor for more profound and
comprehensive cognitive and emotional
dysfunction. Eating disordered patients
who suffer an unhealthy relationship
with food more significantly suffer
unhealthy relationships with the self,
others, and the world around them. The
capacity to nourish one’s own body and
self demands sound judgment, wise
decision making, effective problem
solving, and responsible self-care which
depends on good self esteem and
self-respect. Re-feeding requires
resourcefulness, exercising sound coping
skills and the capacity to face life and
self head-on. Through the quality of
their relationship, eating disorder
therapists become pivotal role models,
lending their egos and enhancing
cognitive function, facilitating
honesty, offering alternatives,
shepherding problem resolution,
defining, facing, and resolving life
problems as they arise, moving forward
with the courage to ask and answer the
hard questions. Eating disorder
therapists are more than therapists;
they are life coaches and parents,
educators and cheerleaders, role models
and human beings.
Contact Abigail if
you might be interested in receiving
future installments of this book.
An internationally renowned
expert in the treatment of eating
disorders, Abigail H. Natenshon, MA,
LCSW, GCFP is a psychotherapist who has
treated children, adults, couples,
families and groups for the past 34
years. The author of
When Your Child Has An Eating Disorder:
A Step-by-Step Workbook for Parents and
Other Caregivers (Jossey Bass
Publishers, 1999). Abigail is the
founder and director of Eating Disorder
Specialists of Illinois: a Clinic
without Walls. She hosts three
informative web sites,
www.empoweredparents.com,
www.empoweredkidZ.com, a
wholesome alternative to the
pro-anorexic web sites, and
www.treatingeatingdisorders.com
designed specifically for health
professionals and educators. She has
appeared on national television as an
eating disorder expert on The Oprah
Winfrey Show, The John Walsh Show,
Starting Over (NBC) as well as on
MSNBC and National Public Radio.
Abigail is also a Guild
Certified Feldenkrais Practitioner based
on the work of Dr. Moshe Feldenkrais,
where she has become a leader in using
this neurophysiological approach to
augment more traditional approaches to
treating patients with eating disorders
and body image disturbances.
Particularly effective in treating
long-term sufferers of eating disorders,
victims of rape, sexual abuse, and
self-mutilation, this technique creates
a novel experience of body and the self,
offering patients enhanced
self-awareness, and new options for
personal growth and change.
Abigail speaks widely to parent
and professional audiences and maintains
a private practice in
Highland Park,
Illinois
where she resides with her husband.
Listen to Abbie's empowering
message to parents. (MP3; Time: 9 mins
41 s)
