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)


HomeBook PreviewAbout AbigailThe WorkbookProfessional ServicesArticlesTestimonialsContact

All Contents © Copyright 2000-2006 Abigail H. Natenshon