Eating disorders

The unique role of the health professional in treating eating disorders

By Abigail H. Natenshon, MA, LCSW, GCFP

Eating disorder psychotherapy, counseling, and medical modeling require a special use of the professional's self, special skill sets, and specialized knowledge.

1. The first challenge is that of recognizing disease, a topic that has been discussed at length in Recognizing Disease. Recognition requires knowledge, the capacity to approximate and anticipate, commitment to the process in terms of taking initiative, and proactive intervention.

   In seeking to identify an eating disorder, it is important to become aware of how much evidence you need in order to know that an eating disorder exists, or that it is in the process of forming. The most astute and effective practitioner is the one who has the clearest vision of the potential for disease onset, having the least amount of information to go by.

2. The second greatest challenge is that of professional intervention. As described in depth in The challenges of effective intervention, one of the more unique elements associated with eating disorder intervention includes:

   The professional's use of self: The use of self with eating disorder treatment becomes uniquely challenging because the treating professional is required to deal with his or her own emotionally charged personal issues around food, eating, weight management and body image. The patient's issues could trigger a response in the unsuspecting professional that could hamper the quality of the treatment offered. Unless fully aware, cognizant and mindful of one's own poignant issues and concerns in these spheres, the professional is at risk succumb to an obstructed vision of the patient, the problem and his or her own role in managing these. Professionals are people, first, with all of humanity's foibles and vulnerabilities. Professionals need not be immune to having problems of their own; nor should they presume to have all of the answers. What they do need to be is self- aware and versatile within themselves and in their responsiveness. The following are real life examples of professionals bringing personal issues to their work in a non-productive way.

   A patient worked with a therapist for over a year, yet chose not to discuss her bingeing/purging behaviors with her. When asked why, the patient explained that the therapist became weepy,"tearing up" whenever she spoke of her struggle with food.

   Another patient recovering from anorexia was struggling with the compulsion to over-exercise. Her concerned parents asked this young woman to discuss this problem with her therapist. Somewhat codependent herself and fearful of riling her patient, the therapist's need to appease and reassure took the place of attending to the unresolved issues at hand. She gave the patient the official go-ahead to continue exercising. Being unable to set limits and provide the necessary reality testing for her patient, this therapist missed a golden opportunity to help this patient grow and heal. How much more productive the dialogue could have been with "Tell me what you are doing, how is it different from before? What makes you think, or fear, that it might be excessive? Have you tried to alter these behaviors? What worked? What didn't work? What else might you try? How difficult is it for you to discuss this problem?"

3. A second major challenge for the professional is the unique requirement for the therapist to seek out and collaborate with professionals in other disciplines in the context of the treatment team. This team would hopefully be inclusive of parents and family. Typical objections of patients and parents to the idea of using the team approach to facilitate treatment are the prohibitive costs involved in working with multiple practitioners. Ironically, the efficacy of this collaboration makes it the most economically feasible alternative in the long run.

   Successful collaboration requires a team-based congruence of skill sets, of treatment philosophy, and of the "family system" bias. Inpatient clinics provide the most viable and workable milieu for professionals who operate under the same roof, as well as an efficacious source of support for patients. Outpatient treatment networks can be just as effective, however, when composed of competent collaborative professionals with like treatment philosophies, depth of treatment experience, and commitment to the healing process. Professionals sharing cases need to collaborate on a regular basis in order to guarantee an enhanced experience for the patient and for himself or herself.

   Professional treatment teams create the inevitable challenge for professionals of dealing with a random mix of personalities, with differences in treatment philosophies, and with the potential power plays that tend to occur among and between professional individuals with different treatment styles and approaches.

   Professionals should anticipate an overlap of function between the various disciplines, though taking heed when there might be excessiveness in this regard.

   Take for example the medical doctor who might attempt to micromanage the therapist's work, or the nutritionist whose focus might be too heavily weighted towards discussing the emotional aspects of food and eating to the exclusion of discussion about a food plan and the client's adherence to it.

   The wide range of professionals involved with eating disorder intervention requires a deep commitment on the part of each practitioner to the process, to the client, to the details of the case and to a successful outcome. These tasks require availability for unpaid cumulative time spent in conversation on the telephone, with parents of youngsters living at home, with out-oftown parents whose child is living away at school, with other collaborating professionals, etc. Team members need to communicate frequently and conscientiously with each other about patients they share, be it over lunch, on the phone, via fax, or email.

   One of the most important criteria for me in choosing to work together with a medical doctor on the treatment team is whether that doctor cares enough about the patient and the treatment process to call me to inquire about the patient's treatment progress prior to seeing the youngster, particularly if the visits are spaced far apart (every couple of months or so).

4. The unique nature of the disease provides its own set of special challenges for the eating disorder professional.

   Eating disorders are integrative diseases that require the professional's integration of knowledge about various aspects of the eating disordered individual's persona, psyche and physiology. The helping professional, no matter what specific aspect of the disease he or she addresses, will affect the entire disease system and the entire individual. There must be therapeutic attention paid to the gestalt—to the body, the psyche, the emotions, and the social and cognitive functions. This attention needs to be on-going and simultaneous.

   Eating disorders, because of their nature, impair the emotional faculties that would ordinarily allow a person to heal. The malnourished brain has little or no access to feelings, accurate cognition and self-perceptions.

   Problem solving, and most of all, the will or desire to recover, is impaired. The eating disordered individual?s brain is further disabled by depression, anxiety, and a sense of hopelessness. Initially, the patient will be required to approximate healthful behaviors and responses, and eventually to grow into them through "leaps of faith" initiated, motivated, and guided by the strength of the therapist/patient connection.