The
Health Professional’s Unique Use of Self
in Treating an Eating Disorder
North American Serial Rights 2009
All Rights Reserved
By Abigail H. Natenshon MA, LCSW, GCF
After approximately
40 years of research in the field of
eating disorders, there are still more
questions than there are answers when it
comes to treatment. Professional and
personal challenges lurk within the very
nature of these disorders and the
diversity of systems that make up the
disease, treatment and recovery
processes. Treating professionals of all
types typically find themselves
untrained, under-trained, poorly
trained, misguided or otherwise ill
prepared to handle these challenges.
Pediatricians and therapists who refer
children out of their practices for
eating disorder specialization testify
that they rarely ever see these patients
again for general care. In the United
Sates today, 87 percent of the reported
11 million victims of these most lethal
of all the mental health disorders are
children under the age of 20. The time
is ripe for recognizing these challenges
and creating solutions.
Diagnostic myths and decoys
None of us are immune to falling prey to
the wholesale myths and misconceptions
coloring popular views about healthy
eating, eating disorders and their
treatment, and parenting afflicted
children. Many consider eating
dysfunction or idiosyncrasy to be a
benchmark of adolescence, a benign
"teen-age girl thing," a passing phase
to be outgrown. It is not uncommon for
professionals to assume that anorexics
are emaciated individuals who do not
eat; that fat-free eating or instinctive
eating defines healthy eating; that
adolescence, being a time of emotional
upheaval, is naturally a time of body
image dissatisfaction. Many believe it
is "normal" for teenage girls not to
menstruate regularly. Pediatricians too
frequently overlook or diminish
precipitous weight loss in children as
long as the numbers fall anywhere within
the range of normal on growth charts.
Parents of eating disordered children
typically assume that normal lab test
results signify a clean bill of health.
Cardiologists attributing low heart
rates to athleticism will typically miss
a diagnosis of anorexia; gynecologists
regularly prescribe birth control pills
for amenorrhea with the assumption that
bringing on a pseudo-period will
counteract or reverse bone loss,
potentially insuring reproductive
functionality. Many professionals
believe that when weight is restored to
normal, recovery has been achieved and
that the psychotherapy process must
exclude parents to insure
confidentiality and rights to privacy
for the child patient. The most
debilitating of commonly held myths is
that eating disorders are incurable.
Practitioners also tend to be thrown off
course by a myriad of seemingly
illogical and counterintuitive treatment
realities specific to eating disorders.
For example, the process of eating
disorder recovery feels worse than
illness, and patients typically do not
recognize their condition to be
unnatural or problematic. They must
learn to eat more food more regularly
(to stimulate their metabolic function)
to weigh less. Full recovery only
tangentially concerns food and weight
management. Eating disorders threaten
lives even as they create the illusion
of preserving them, making resistance to
recovery an on-going reality throughout
the course of the treatment process.
Personal challenges for clinicians
Further muddying the treatment waters,
as treating professionals, we are all a
little "disordered" in the ways that we
eat and relate to food. A person needn't
be bulimic or anorexic to overeat or
under-eat at times, to eat or not eat at
times in response to stress, sadness or
boredom. Moreover, it is easy to lose
sight of what healthy eating truly is in
a society obsessed with dieting and
thinness, where restricting food has
become a national pastime and a highly
sanctioned norm. We all harbor personal
views, attitudes, issues and biases
about eating and weight management,
which, unless recognized, dealt with,
and contained behind clear (though at
times semi-permeable) boundaries, could
obstruct our objectivity and
responsiveness in treating these
disorders. Because the process of eating
is a normal function and requirement of
daily living, many treating
professionals assume they are
sufficiently expert on the subject
simply by virtue of their own personal
experience and perspectives on food,
eating, and weight management.
A highly significant phenomenon peculiar
to this specialty is the vast number of
professionals in this field who are
recovering, or have recovered from
clinical eating disorders themselves.
First- hand experience with these
diseases and their recovery becomes a
great motivator for professional
specialization. The prevalence of those
who have recovered from eating disorders
in the treatment field is so significant
that a well respected treatment facility
in California describes itself as having
been "designed and created by recovering
professionals to help women suffering
from anorexia nervosa, bulimia nervosa,
and exercise addiction." (footnote)
Though personal experience with disease
can be a boon to a practitioner's
sensitivity to eating disorder issues,
those that remain unresolved can lead to
mismanagement of cases and transference
phenomena impeding the professional's
capacity to observe and respond. A
patient of mine spoke about having
previously worked with a therapist who
had recovered from anorexia; "Her eyes
would well up with tears when I would
begin to speak about my disease" she
explained, leading her to steer clear of
bringing up the topic.
Dealing with pervasive resistance and
denial can become "too close for
comfort" for practitioners who dislike
or fear the consequences of honest
confrontation; those not sufficiently
self aware or facile in keeping their
own boundaries firm may risk losing
themselves and their professional
objectivity as they enter family
systems. Eating disorder treatment
presents on-going stressors and
challenges for practitioners that
correspond in nature, kind, and
intensity to those that face their
eating disordered patients; eating
disorder practice requires inhabiting
the same uncomfortable ambiguities and
approximations that we persuade and
embolden our patients to tread and
conquer. Along with their eating
disordered patients, practitioners must
learn to tolerate and accommodate the
murky realities of the unpredictability
of this healing process, sustaining a
genuine and far-sighted commitment to a
healing connection throughout the
long-haul. Professionals need to learn
to use themselves as whole and complete
individuals, integrating self-awareness
with resiliency, skills and personal
confidence to roll with the vicissitudes
of the evolving treatment process. This
field is clearly not for the
chicken-hearted.
The state of the treatment field
For health professionals who schooled
prior to the 1970's, the dawn of an
awakening of eating disorder awareness,
there was virtually no information about
eating disorders and their treatment
available. Now, even after 40 years of
research and experience in the field,
eating disorder treatment typically
falls between the cracks of formal
education. Curriculums within graduate
schools overlook the unique treatment
requirements of these diseases by
refusing to offer specialty courses. A
student currently being trained at a
highly reputed social work graduate
school reports that when she inquired
about why there were no courses
dedicated to the specialized treatment
of eating disorders, she was informed
that specialty training for eating
disorders would be "unnecessary and
redundant" based on the existence of
more generic courses addressing the
issues giving rise to the disorders,
such as human development, self-esteem,
mood disorders, and issues of control
and identity. In fact, generic treatment
protocols will not stand up to the
unique requirements of insidious mental
health diseases that concurrently
present long-term and deadly risks to
physical health and well-being.
Because few of us have been exposed to
formalized training in professional
schools, clinicians on the front lines
of eating disorder treatment fail to
recognize what they do not know, thereby
losing sight of what they need to learn
….about themselves, their patients,
these disorders, and the obstacles that
potentially impede sound and effective
treatment. Nor do they know where to
look to find answers to questions that
in many instances even the most
competent and experienced of them do not
even know how to formulate.
In the face of ever-increasing numbers
of cases reflecting an ever younger
patient population, there are simply not
enough adequately trained specializing
professionals available to meet patient
numbers and demands. This is hardly a
surprise in light of a story that my
business partner and co-director of
Eating Disorder Specialists of Illinois
tells; this highly skilled nutritionist
speaks of the advice of her graduate
school advisor who discouraged her from
working with eating disorders, making
the case that "the work is tough, the
clients resistant, the changes minimal,
and the liability risks enormous; people
die from these disorders." A February
2005 online article through the BBC News
Service cited a survey showing that the
majority of people with eating disorders
are not receiving the recommended level
of care, that 55 percent of sufferers
were not treated by a
specialist.(footnote) The report found
that only 14 percent of patients,
caregivers and professionals questioned
said eating disorders treatment had been
available close to home. For some people
the nearest appropriate specialist
service could be up to 150 miles away.
More than 50 percent of eating disorder
cases remain undiagnosed and untreated.
A questionable correlation between
research and expert practice
In the field of clinical practice,
evidence-based outcomes are becoming
increasingly valued and apparent across
the board. This trend is evident in
graduate schools of social service that
typically offer fewer courses in
psychodynamic and interpersonal
therapies, with a greater emphasis now
on non-clinical, "macro" approaches…on
administration, statistics and hard
research. Health insurers, too, seek the
validation of quantifiable and
predictable outcomes, reinforcing the
increasing commitment to evidence-based
care. Contributing to a deficit in the
clinician's learning curve is the
ever-deepening phenomenon of an existing
rift between the science and the
practice of eating disorders, between
researchers and clinicians, between left
brained discoveries and right brained
treatment applications within the field.
Existing literature tends to be highly
theoretical and reductionist, the work
of academics and scientists who have
limited access to the treatment venue.
Its relevance to a highly integrative
and relationship-based disease and
treatment systems is limited.
Treatment failure can be the result of
several factors, many of which are
beyond our control. Personality factors,
brain chemistries and the occurrence of
heritable qualities within a patient's
DNA are givens. "Treatment mileage" and
life circumstances become critical
factors in determining a patient's
recovery outcomes as well. Typically
however, either through acts of
commission or omission, it is the health
professional who drops the ball by
failing to offer consistent expertise
and competency where positive outcomes
are clearly within reach. If
practitioners are not prepared to
subscribe to basic underlying
evidence-based principles, their efforts
are certain not to succeed. If they
offer these same principles outside the
context of a secure and trusting
therapeutic relationship, they can also
be assured of a limited outcome.
Finding solutions within the
therapeutic relationship
Though in some respects elusive, the
tools of this eating disorder treatment
trade are actually supremely accessible;
in many respects they are disarmingly
simple and they are hardly strangers to
most psychotherapists. We know them all;
we know how to implement them. We simply
need to learn which to use, when, where
and how to use them in the unique
context of these disorders… in what
sequence, combinations, and in what
manner. In addition, we need to learn
how to access their most valuable
personal resource of all…ourselves. It
is through a caring and intentional
quality of therapeutic connection that
the seeds of successful outcomes become
fertile and alive, and that the
treatment environment becomes a safe and
trusting place to learn. Through a
developing trust in the therapist and
the therapy process the patient
ultimately develops the capacity to
trust in his or her own self. The human
relationship is the vehicle through
which people grow and heal best, the
means through which science becomes
operational and personalized. Therapists
do not cure these disease; they inspire
the patient to heal her/himself through
the quality of the therapeutic
connection.
Andre Agassi, tennis champion and title
holder for close to two decades, spoke
eloquently at the 2006 U.S. Open after
losing one the most memorable matches in
the history of tennis that would send
him into his retirement. Speaking with
gratitude to an adoring crowd of fans,
he said, "You have willed me to succeed,
sometimes even in my lowest moments. And
I've found generosity. You have given me
your shoulders to stand on to reach for
my dreams, dreams I could never have
reached without you." He spoke a healing
truth that is as pertinent for eating
disorder recovery as it is to the
professional athlete. It is the quality
of the human connection that inspires
and that heals.
Establishing quality healing therapeutic
connections requires unique personal
characteristics within professionals
treating these disorders.
Therapeutic care-taking for eating
disorders demands:
-
An awareness
and creative use of self in
accommodating the ever-changing
requirements of the therapeutic
moment and in creating the human
connection.
Professionals need to become
perpetual learners; they need to
become students of their patients
and of the treatment process,
maintaining humility in the face of
the complexity and far-reaching
effects of disease, treatment and
recovery. "Know thyself" is a most
pivotal requisite for treating
health professionals. It is through
the strength and substantive quality
of the therapeutic relationship that
the patient accrues the knowledge,
the ego strength, the emotional
facility, and the necessary
self-trust to create, or recreate,
his or her own healthy self.
An exercise from When Your Child Has
an Eating Disorder: A Step-by-Step
Workbook for Parents and Other
Caregivers (Natenshon, Jossey Bass
publishers) pages 53-55 fosters the
therapist's self-awareness.
-
A tolerance for
ambiguity and a willingness to
engage in intentional, purposeful
and courageous risk taking.
The practitioner must exhibit
courage and confidence in taking
on-going personal risks of
self-disclosure, of confronting
taboos and ambiguities, of creating
discomfort, hostility, conflict and
resistance to treatment, of
potentially alienating the patient
in the process of attempting to
eradicate the disease, of making the
tough demands required to maximize
opportune moments. This work is not
for the chicken-hearted among us.
-
A widely
integrative thinking style; the
practitioner holds the "big picture"
of disease, treatment approaches,
protocols and recovery, even while
attending to the small behavioral
changes that are the currency of
healing.
Eating disorders resist lending
themselves to one-size-fits-all
orthodoxy in treatment approaches.
Treating a highly diverse disease,
therapists must be capable of
drawing upon therapy approaches as
diverse as interpersonal
psychotherapy, psychodynamic
psychotherapy, cognitive-behavioral
therapy, solution-based brief
therapy, self psychology, gestalt
therapy, group therapy, family
therapy, expressive therapies,
referral, consultation and crisis
intervention techniques. The
combined selection of treatment
approaches need to be based on the
needs of the patient and therapeutic
moment.
-
An
action-oriented, outcome-driven,
highly intentional treatment style
to keep up with the pace and
momentum of a hard-driving disease
and disease process.
Paralleling the nature of disease
itself, the treatment of eating
disorders cannot afford to become a
stagnant progress; the clinician
must be proactive in driving the
healing process forward. Eating
disordered individuals are either
getting better or they are falling
deeper and deeper into an abyss of
pathology. Treatment will simply not
flourish in the face of passivity,
of non-directive attempts to bond
with the patient through small-talk.
In approaching the eating disordered
individual, addressing and
stabilizing bodily needs and
function becomes a primary priority,
saving lives and preparing the
ravaged brain to accept the
therapeutic treatment process.
-
An on-going
assessment of changing needs
followed by an expansive use of
resources... of diverse therapy
techniques, modes, multi-level care
venues, along with a
multi-disciplinary treatment team
including parents as valued
treatment partners.
Treatment must be continually
assessed, custom-tailored, up-graded
to accommodate the recovering
individual's changing needs, stages
of readiness, life experience, and
conditions in flux within external
support structures. By holding the
vision of the comprehensive patient
system, therapists become better
equipped to access available
resources which include families,
collaborating team professionals,
schools, athletic coaches, and
multi-levels of care as adjuncts to
out-patient care.
It is critical that
professionals who seek guidance in
treating eating disorders not look in
all the wrong places… seeking linear
solutions when conceptual ones are
needed, seeking theories and concepts
when behaviors are required, seeking
perfection when healing resides in
approximations, seeking control when the
best standards for measured growth lie
in the capacity to solve problems
effectively and to roll with life's
punches.
Eating disorders are disorders of life
and living; healing them upgrades the
patient's quality of function in all
life spheres. Eating disorder
practitioners are life coaches,
advocates, teachers, parent substitutes
and self-objects whose influence
supersedes the therapeutic moment and
the patient's relationship with food to
impact global problem-solving,
self-regulation and self-care.
Successful eating disorder treatment is
transformational, the work saving lives
and upgrading life quality, filling in
missing developmental milestones and
setting the stage for successful
function throughout life. In working
with this patient population, the stakes
are high, but so are the rewards. Eating
disordered patients and their families
have a right to expect and demand the
highest quality care, predictably and
consistently. It is our obligation as
professionals to provide that care and
save lives.
Listen to Abbie's empowering
message to parents. (MP3; Time: 9 mins
41 s)
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