Eating disorders

The challenges of effective intervention

By Abigail H. Natenshon, MA, LCSW, GCFP

What to do first

First and foremost, the patient with an eating disorder needs to be evaluated by a medical doctor, to first rule out organic problems that may be the cause of the appetite or weight loss. It is unfortunate that in all too many cases where life-threatening medical problems have been overlooked and diagnoses missed, lives have been lost.

The earlier the intervention with the eating disordered individual, the more potent is the likelihood of a successful outcome. Intervention can take place at any place along a continuum of disease development and cure. The earliest and most effective intervention, called primary prevention, occurs within the context of the family. This type of intervention takes the form of parents providing and serving nutritious meals for the family, and role modeling for their child:

• a healthy eating lifestyle
• a healthy exercise lifestyle
• healthy attitudes about the body
• yhe capacity to face feelings and resolve problems effectively

The next level of intervention, known as secondary prevention, involves recognizing an eating disorder in its beginning stages and attempting to nip the disease in the bud by confronting the individual and the problem, and attending to them both in an effective manner. This task falls largely to parents, but at times, to the medical doctor, educators, youth leaders or health practitioners—to whatever person is in the position of noticing a problem that has yet to be diagnosed.

Providing treatment for a clinical eating disorder is called tertiary prevention. By intervening with treatment at any point in the disease process, the prevention that occurs involves minimizing the deleterious effects of disease and preventing death.

Psychotherapy for eating disorders addresses the dysfunctional eating behaviors as well as the emotional issues that underlie and drive those behaviors. Eating disorder therapy needs to be cognitive and behavioral in its bent, with a here and now "process" orientation and with a mind for the effects of the family system on the afflicted individual and on the effects of disease on the family system. Psychotherapy needs to be performed in the context of a deeply trusting and dynamic psychotherapeutic relationship.

As professionals, I urge you to use my book, When Your Child Has an Eating Disorder: A Step-by-Step Workbook for Parents and Other Caregivers creatively for your own purposes, as well as for your patients'. I invite you to use the workbook exercises with groups, with families, or individual patients, adapting their contents for weekly tasks or assignments that will provide incentives for parent/child interaction, self-awareness, self-acceptance, and the discovery and acknowledgment of personal issues.

In addition, www.empoweredparents.com and www.empoweredkidZ.com are an important source of visitors' information and initial consultation free of charge.

www.empoweredparents.com offers upwards of 100 informative articles and mini-articles on the subject of eating disorders, body image concerns, and related topics.

www.empoweredkidZ.com is a wholesome alternative to the pro-anorexic sites that continue to proliferate across the web. This site contains 30 articles answering kids' questions about healthy eating, healthy weight management, eating disorders and body image concerns. Here is a place where kids can ask for the help they need, even when they might feel too afraid or too embarrassed to seek guidance elsewhere.

Eating disorders create unique challenges for professional intervention;

1. There is nothing indirect or passive about any aspect of eating disorder intervention. It requires the therapist's active use of self, not just for diagnosis, but for treatment, and for the support of the eating disordered individual and his or her family through a most challenging recovery process.
2. In most instances, health practitioners will recognize a disease first, and then intervene. With eating disorders, some form of proactive intervention or use of self may be a prerequisite to recognizing or defining the problem at hand.
3. Diagnostic intervention with eating disorders is about more than defining a problem. It is about bringing the individual to her own problem awareness and recognition, acceptance, and assistance. People with eating disorders are typically loath to admitting to themselves that they have a disease. In some instances, they feel and look better than ever, empowered and appreciated for their show of selfdiscipline and will power. In other instances they fear admitting to an eating disorder, under the misconception that an eating disorder "is forever"—that there is no cure, or that an eating disorder indicates mental illness or insanity.
4. Diagnosis with eating disorders is not a one-time process, but an ongoing dynamic that takes place throughout the therapy process. Some element of diagnostic thinking and assessment needs to be part of the content of every therapy session. Through astute diagnostic listening, patients need to be assessed continually for changes made that represent progress towards recovery, as well as for the appropriateness of possible referral to alternative milieus such as hospital day programs or residential placement.

5. Even the act of therapeutic listening needs to be proactive. Active listening is listening in a way that allows the patient to know herself better. It is accomplished by responding to the patient's "feeling messages" that underlie the content of the communication.

   In using an example that was cited in a previous chapter, the child who approaches a table full of dessert snacks at a youth group function, eyes a plate of donuts and remarks, "Nobody eats donuts." Here is a comment that might deserve deeper, "diagnostic" listening on the part of the youth group leader, peers, or of anyone in earshot. This remark represents a clear statement about the child, her attitudes and her thinking—it is hardly about the food of which she speaks. In an effort to use this opportunity to educate the child, (and not judge or control her), the listener would do well to investigate further, having the youngster expand on the statement. "Tell me about what you mean."

   Going further with the questioning, the questioner might help the youngster to recognize where this notion comes from, if it represents a fear that she has about eating certain types of food, if she entertains worries about her weight, if she seeks to lose weight, and if so, how she might be setting about to do so, etc.

6. Whether the person intervening is a family member or health professional, one's own personal issues around food, eating, weight, body image and the emotions underlying theses subjects have implications not only for what that person sees, but also for if and how he or she may choose to respond. For the person who may be reluctant to engage in conflict or confrontation, the act of approaching a person who exhibits resistance to acknowledging an eating disorder can be stressful. The realities of these diseases and of the anger (resistance) that may surface in response to addressing them could possibly extinguish a person?s impulse or motivation to investigate further. It takes courage to persist in such an effort responsibly and effectively, in tune with the requirements and opportunities of the moment.

In considering the challenges of intervention, perhaps the most difficult of them all is separating out what, in our society, what is normal and what constitutes "pathology" when it comes to eating. There is a thin line between benign "quirky" eating, disordered eating, and the habits that constitute a clinical eating disorder. With 40 to 50 percent of young women on college campuses today being disordered eaters, normal eating is no longer one and the same as healthy eating.