Book Introduction: The Professionals' Guide to Treating Eating Disorders

How this treatment guide can be helpful to you

The following conversation will clarify what sets the treatment of eating disorders apart from the treatment of other physical and mental health disorders… what makes these problems and patients as unique as they are, and what makes the practitioners’ use of self in attending to them so novel and challenging. The resources provided here are for you if you are a physician, a PhD. psychologist, a social worker or counselor, nutritionist, nurse, coach, educator, or student of any of these disciplines. It is for you if you are just starting out in your career, or if you have been a “veteran” in practice for years or even decades, if you are now treating patients with anorexia, bulimia, compulsive overeating or binge-eating disorder, or you look forward to treating eating disordered individuals and their families one day. As a resource, it will walk you, step-by-step, through the body of knowledge, skills, and techniques you will need to most effectively prevent, diagnose, and treat these patients and their families. The practical and useful information included here is based on tried and true techniques that have been effective in my own professional practice of psychotherapy with a specialty in eating disorders these past 34 years.

Eating disorders are unique, and so are their requirements for treatment. Unless a professional has had extensive inpatient or outpatient experience working with these problems, supervision from an eating disorder expert, or formal training of some other kind, he or she may not be adequately trained or may not feel sufficiently prepared to offer the patient and family effective treatment. With the information provided here, you will no longer need to feel compelled to refer your eating disordered clients to specialists outside your practice. With the exception of those occasional difficult cases that may be beyond your ken, this e-book will provide the grounding you need to begin working productively with this patient population yourself. You can rely on your patients and the treatment process to teach you whatever else you will need to know.

The unique nature of eating disorders determine the unique requirements for their treatment

Eating disorders are global, pervasive and consummate…so must be the focus of their treatment. Anorexia, bulimia and compulsive overeating exist at the very core of the afflicted individual. They feel to the client as though they permeate every cell, forming the underpinnings of every aspect of the individual’s lifestyle, personality, attitudes, values, quality of relationships, and generalized function. Diseases of the body, the psyche, the cognitive mind and soul, they evoke depression and fear, limiting the victim’s function and quality of life. Every aspect of these integrative diseases must be addressed simultaneously.

An eating disorder is a misuse of food to resolve emotional problems. These are integrative diseases, forming a part of every aspect of the afflicted individual’s personality structure and function. In order for recovery to be effective, every aspect of the disease must be addressed simultaneously. Do not be misled into assuming that by treating the underlying emotional problems that drive these behaviors, the dysfunctional behaviors will correct themselves. Nor can you expect that behavioral changes alone, such as weight restoration) are sufficient to mark recovery from an eating disorder. When a practitioner compartmentalizes the focus of eating disorder treatment, (s)he will have overlooked the most central reality of working with diseases that are so multi-faceted and integrative. In so doing, (s)he risks enabling the patient’s belief that the disorder and/or its symptoms are temporary or somehow not significant, that they concern the benign wish to lose a few pounds, or play only a peripheral role in the patient’s life function, that they can be counted on to disappear of their own accord or at the patient’s will. Eating disorders are dynamic and ever-changing diseases; you can be assured that an eating disorder is either getting better, or it is getting worse.

There is nothing arbitrary about the onset of an eating disorder, and there must not be anything arbitrary about their treatment, recovery and cure. The most lethal of all the mental health disorders and increasingly prevalent among a patient population younger than age 12 and older than age 20 (87 percent of eating disordered individuals are children and teenagers under the age of 20), there are too few graduate programs or post-graduate courses that teach physicians, nutritionists, and mental health professionals to deal specifically with this practice specialty. Learning to treat these diseases effectively is in some ways analogous to learning the art of effective parenting; it is perhaps one of the most difficult, significant, and “under-taught” tasks a practitioner will ever face. Too frequently, these difficult lessons are left essentially to instinct and feel, trial and error. The stakes with these diseases are clearly too high to rely on a random approach. The lives of victims young and old are hanging in the balance. This e-book will attempt to fill what has been, to date, a gaping void in most professional trainings. Treating eating disorders is a task that not every therapist may be cut out for; but… if it is to be done at all, it needs to be done right.

What sets this treatment of eating disorders apart from that of other diseases?

Because eating disorders are integrative in nature (affecting the mind, body, emotions, personal relationships etc.), they require an integrative vision and approach to healing, one that includes a coordinated and multi-disciplinary “team” of health professionals, which might include the medical doctor, psychopharmacologist, individual, family and group psychotherapist, and nutritionist. In the younger patient living at home and going to school, teachers and school personnel may also need to become part of the treatment team in some instances, as will parents, siblings and other family members.

Also unique is the central role of parents and family in the treatment of youngsters afflicted with an eating disorder. Eating disorders are family diseases. Living alongside the suffering child, parents and families suffer, too, victims of the disease process in their own right. They, too, require treatment, coaching and TLC. Parents frequently have no choice but to find themselves “diagnosticians,” as these diseases rarely come to light in the doctor’s office or even in lab tests, but instead show up at the family dinner table or in the family bathroom.

Siblings too, suffer profoundly from the disruption of family dysfunction that eating disorders create. If educated and encouraged to join the process of family treatment, however, siblings hold the potential to become the struggling child’s greatest asset and support resource. In the process siblings also benefit by learning the courageous art of facing and resolving problems with wisdom and sensitivity.

Though not to blame for causing their child’s eating disorder, there is a great deal that parents can do to prevent and/or to heal these problems once they take hold. The issues driving these diseases typically originate and/or find parallels within the greater family system. In order to best facilitate changes in any one particular aspect of any system, the entire system needs to change. Research out of the Maudsley Hospital in London, England has demonstrated conclusively that the most effective treatment mode for the child living at home and who has been anorexic less than three years is family treatment.

Parents have the potential to be their child’s greatest source of strength in surviving and overcoming an eating disorder. To function at their best for their child, parents need to be educated and supported through the treatment process so that they can in turn become, and remain, supportive to the ever-changing child and recovery dynamic as it unfolds. If not part of the treatment process and the solution, parents are at risk to become part of the problem. Depending on the age and needs of the child and the willingness and facility of parents to become involved effectively, the family’s role will vary case to case, from diagnostic only, to periodic, ad hoc, or on a regular weekly basis. The parents’ role will need to be ever changing in the face of an ever-changing youngster with ever changing needs. It deserves mention here that adult eating disordered patients too, remain connected with and affected by parents and families in significant ways. Where family input is possible, it can have invaluable benefits for the treatment process.

In some cases, parents themselves struggle with issues having to do with eating and body image concerns. Though they may not be clinically ill themselves, parents who are disordered eaters or compulsive exercisers are potent role models to children in recovery who become easily confused and misled. In this capacity, parents need to know themselves, confront their own issues, understand and take responsibility for their effect on their recovering child. Some parents may display a damaging resistance to admitting that their child has a problem.

When the victim of the eating disorder is a married adult, the eating disorder is likely to become “triangulated” as an emboldened third party and an integral part of the marital system. In some cases, the eating disorder cannot be dislodged without informing and educating the spouse or partner about how the system might be perpetrating or prolonging the disease syndrome when it might otherwise be recruited to alleviate it.

Eating disorders are unique, too, in that the recovery process invariably feels worse (more frightening and anxiety-provoking) than does the disease. Eating disorder recovery process demands courage and tenacity as the patient, who invariably fears change and the unknown, is required to use herself flexibly to accommodate the reality and requirements of the moment, to face herself, the world, and the uncertainty of her future without the use of the eating disorder as a coping mechanism. It is the rare eating disordered patient who has access, at the start of treatment, to the internal resources required to confront and resolve the emotional and behavioral problems plaguing him or her. 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, her healthy self. The process requires foresight, hindsight, and constant vigilance, to track a recovery process that is often hard to decipher, and frequently elusive.

Also setting these diseases and their treatment apart, individuals who suffer from eating disorders tend to be bright, charming and wholly lovable. I feel fortunate to be able to say that, for the most part, I truly “love” my patients and actively look forward to working with the vast majority of them. This is highly gratifying work where much of the excitement stems from the quality of the therapeutic relationship. Through the work, skilled therapists enjoy the privilege of walking side by side with clients through a process of growth and development that takes them, like the phoenix, out of the ashes to an optimistic resolution of problems and the development of coping skills leading to a lifetime of improved function and connectedness with self and others.

This work is not for everybody

Having discussed the unique quality of these diseases and their treatment requirements, it deserves to be mentioned that treating eating disorders is not for everyone. Eating, weight management, and body image concerns, highly prevalent in our society in general, may plague eating disorder practitioners, hindering their objectivity and their capacity to observe, prevent, or address these problems. A unique phenomenon among eating disordered therapists is that many have recovered from their own disorder at some earlier time, creating a greater degree of susceptibility to transference issues that might arise and insinuate themselves into the therapy process.

There is no dearth of challenges for eating disorder practitioners to handle. Control issues, which typically play themselves out interpersonally, lie at the very core of the individual struggling with an eating disorder. Resistance to the therapy work and to the changes they bring are predictable, and must be anticipated, gleaned, and confronted squarely throughout the recovery process. Patients typically feel loath to make changes and to become fully committed to the idea of recovery even after the treatment and recovery has been well underway. The recovery process is invariably extended, and in that, discouraging, taking an average of seven to ten years for those anorexics who have been hospitalized. Confusing and confounding to all who observe it, including the treating professionals, recovery typically takes on the configuration of two steps backward, one step forward, an ironic and challenging situation for eating disordered individuals who, more than anything else, crave certainty and predictability. The extended time of recovery provides additional challenges to patients who invariably experience themselves passing through life stages, life crises, life transitions, and other significant passages and life events throughout the process.

How I came to eating disorders as a specialty

Decades ago, as a private practitioner in search of a greater number of family cases for my weekly practice, I approached my neighborhood hospital with the offer to take on a few family cases for them. They hired me to work on their eating disorders unit. In working with this population, it wasn’t long before I was hooked. Though the challenges were great, with the lives and life quality of both victims and family hanging in the balance, the profound benefits from effective treatment remained a seductive draw. Through recovery, I witnessed young adults experiencing a new lease on life, feeling as though they had “gotten their life back; ” Similarly, parents proclaimed that they had “gotten their children back.” Perhaps the purest pleasure for me was the knowledge that the ever-increasing emotional maturity and problem solving skills of the recovering or recovered child foreshadowed an improved life quality and upgraded life function for the emerging adult. Likewise, the quality of the parent/child connection would be enhanced, the bonding secured, for the enjoyment and gratification of both parent and child from that time forward.

Largely, my clientele consisted of eating disordered individuals who had not met with success in previous treatment elsewhere; as a result, I found myself privy to stories about what went on in the treatment practices of other professionals. I found that too many practitioners treating eating disorders misunderstood and mishandled eating disorders and the patients who suffered with them.

A 50-year-old woman who had been anorexic for 30 years spoke, in my office, about a conversation she had had with her psychiatrist 30 years earlier in which she had confessed that she had anorexia. His response was “No you don’t. You are not too thin and not too fat, and so you are not eating disordered.” It was not until three decades later that this unhappy woman was able to commit herself to getting the help she had needed all those years.

Most troubling for me were the stories I heard from parents who spoke with guilt and a profound sense of inadequacy about not knowing how to help and support their child in recovery. Had these children been diagnosed with cancer or diabetes, these same parents would not have known any confusion about how to support their child in getting help. It was an interesting phenomenon that when the problem was eating disorder or body image centered, parents felt nonplussed. Many of these parents had been excluded from their child’s treatment, advised by well-intentioned professionals not to “interfere” in their child’s food or eating disorder treatment for fear of “making matters worse.” Even as they enjoyed the potential to become their child’s greatest advocate, they had been cut off from their child, and the healing process.

In another instance, in discussing their need to make a life and death decision about whether or not to hospitalize their eating disordered daughter when her therapist was out of town and unavailable for consultation with the parents and the other professionals on the case, an anorexic child’s parents stated,

“We were flying blind,” they explained later. Our daughter’s very life was in our hands. In seven months of treatment, her therapist had communicated with us only three times, all of which were at our initiative. She refused to involve us in the therapy process, and then wouldn’t disclose any information about Janet’s condition when we asked, for fear of breaching her confidence. Everything rested on our decision, which we were obviously in no position to make. It was a nightmare.”

Yet, this problem could have been unequivocally and easily avoided through proper communication, professional to professional and professionals to parent.

The above quotation is taken from my book, When Your Child Has an Eating Disorder; A Step-by-Step Workbook for Parents and Other Caregivers published by Jossey Bass Publishers in 1999.

With the advent of my web sites, www.empoweredparents.com, www.empoweredkidZ.com, and www.treatingeatingdisorders.com health professionals and educators began seeking information from me about the still largely undefined process of treating eating disordered patients and their families. Hungry for information for and about using themselves in light of their own personal attitudes about body image and eating, they sought guidance, tools and strategies in their practice with these patients. As my feedback had apparently had a profound effect on their therapeutic approach to their eating disordered patients and on the success of the course of treatment, the time appears ripe for further discussion about an effective professional response to these diseases.

My approach to treatment is four-fold.
It is psychodynamic, with due respect to the power of the therapy relationship and an eye to the quality of connection between patient and practitioner, with a focus on the importance of the interactive moment as the greatest resource for the patient’s learning and self-awareness and on the therapist’s creative and unique use of self.

It is cognitive-behavioral, addressing the power of the mind and the intellect to become self-aware, recognizing the self and its functions as the means to access options for change. Behavioral changes that encourage self-awareness, differentiation and the reintegration of self, facilitate learning, and allow the patient’s new knowledge to become firmly rooted.

It is grounded in systems theory, addressing the origin of these diseases and the role of the family in the life and recovery of the afflicted child. The family systems approach is also critical to understanding the role of an eating disorder in a marriage, and the role of the spouse in facilitating or extinguishing recovery changes.

Most importantly, it is grounded in whatever works. I am a strong advocate of using myself in whatever flexible, imaginative and creative ways might facilitate and integrate my client’s learning. My thinking is “outside the box” for the clients as well as for the use of myself in the process. In the end of course, the “bottom line” in working with this or any patient population is providing outcome. My approach to life, as well as to therapy, consists of the Machiavellian belief that no opportunity for learning should ever be forfeited… not yours, and certainly not your patient’s. It is learning, in fact, that keeps us alive, vibrant, and ever youthful human beings.

I frequently conduct sessions with my eating disordered patients over the dinner table, and have used behavioral techniques such as audio tapes with sound-based directives to monitor the pace and awareness of the patient’s chewing. In an effort to awaken their awareness to accurate bodily self-perception, as a certified Feldenkrais practitioner, I have been privileged to able to offer my patients an adjunct treatment alternative, non-verbal and experiential in nature. The hands-on body-centered movement-oriented work of Dr. Moshe Feldenkrais is a potent device to awaken self-awareness and create an internal image of achievement to reduce anxiety, elevate mood, and replace limited, distorted or otherwise poor self and body image with a positive sense of identity and progress towards recovery.

I wish to stress just how central is the practitioner’s grounded, creative and proactive use if self to facilitate a patient’s recovery In offering treatment ideas and tools to serve this population, my hope is to provide a structure through which professionals can first understand and address the problem, establishing a consistent and on-going relationship with a typically “hide-and-seek” motivation to recover, then liberating the practitioner to diverge creatively to accommodate the unique and specific needs of the individual patient, and of the unique moment.

Following are the “nuts and bolts” of how to capture optimally the opportunity that exists within the therapeutic moment, and how to help patients create opportunity within adversity that can carry them successfully through their eating disorder recovery and beyond that, throughout their life and their future.

This eBook is a simple, straight-forward and informative guide for Psychotherapists, Medical Doctors, Nurses, Registered Dietitians, Educators, and other members of the outpatient treatment team. It is a must for professionals who are.......

currently treating patients with eating disorders
who are treating patients who may be particularly vulnerable to developing an eating disorder
who are not achieving the results they seek with their eating disordered patients
who are veterans in the treatment field
who are novices or graduate students
who wish to learn to use themselves with more creativity and facility in treating these diseases
who have been under the impression that referring clients out of their own professional practice is the only way to deal with this specialty
who believe that treating eating disorders is like treating any other mental health disorder
who are doctors, psychotherapists, nutritionists or educators