By Abigail H. Natenshon, MA, LCSW, GCFP

Eating disorders remain the most deadly of all the mental health disorders, killing and maiming from six to 13 percent of their victims. Eighty seven percent of the 11 million victims in America today are children and young adults under the age of 20.  In addition, countless millions of infants and young children suffer with feeding disorders and/or related dysfunctions that may lead to early onset clinical eating disorders. The unfortunate irony is that eating disorders remain amongst the most highly misunderstood, under-diagnosed, and medically and psychologically mishandled diseases; the vast majority of otherwise competent health professionals have no idea how to recognize these diseases or approach their treatment.  The good news is that anorexia nervosa and bulimia nervosa are fully curable in 80 percent of cases when recognized early and treated in a timely and effective manner. 

Every eating disorder is as unique as a thumbprint, defined by the patient’s own heritable factors, personality structure, cognitive, social and emotional development, as well as the structure and quality of function of the family-based “holding” system. Every treatment plan must be uniquely custom-tailored to match the unique requirements of each case.  Treatment effectiveness depends on the practitioner’s knowledge, experience and capacity to use himself as a vehicle to inspire the patient to choose to heal, and to discover the best way to go about doing so. As a practitioner, it is critical that you respect the power and integrity of these disorders, the role of the parents and families in a child’s recovery, and your own responsibility and perseverance in launching and sustaining a successful recovery effort. Eating disorder therapists are more than therapists; they are life coaches and parents, educators and cheerleaders, role models and human beings. As reality testers and limit setters, the practitioner creates a safe learning environment, optimizing the patient’s capacity to change and grow through the quality of the therapeutic connection. 

The Use of Self in Diagnosis

Whether or not you feel comfortable taking on a case that involves treating an eating disorder, your evaluation/assessment of the patient and/or early interaction with the eating disordered child and family could provide the first, and depending upon the success of that session, perhaps the only, opportunity for the individuals in that family to avail themselves of professional care. Your role as a diagnostician is pivotal; in making the first entry into the disease and family systems, and as the stimulus to the creation and development of a patient support system, you could potentially be saving a life. Effective evaluations for eating disorders are more than diagnostic inquiries. They become 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.

The skilled practitioner needs to be both educated and educator, bringing life experience and information to every therapeutic connection.  It is the quality of information and how it is communicated that brings patient and family to an acceptance of disease and the choice to recover, that initiates and shepherds the healing journey. Practitioners must sustain a willingness to remain open, (both personally and professionally) to new self-knowledge through a treatment process that at times gives rise to emotional issues and quandaries that parallel the tasks and challenges of their patients.  This learning might include accommodating the murky realities of functioning through feelings of powerlessness, out of control, unpredictability, and confusion within the treatment and recovery processes; entering family systems without traversing boundaries; and fielding patients’ manipulations, resistance, power struggles and denial.  Professionals need to learn to listen, not only to know the patient, but to know themselves. In so doing, the practitioner fosters the patient’s capacity to listen to know his or her self.

The effective practitioner is capable of holding the wider vision or “big picture” of disease and of long-term recovery goals, even while attending to the smallest of details in the here and now. Using the forward momentum of disease to advantage, (s)he accesses human resources and a variety of treatment options to propel patient and process in the direction of healing, sustaining the vision of the possible in a morass of what may at times seem intractable, unbridgeable, impossible. 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.” 

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. This does not come easily for all professionals, but is essentially what it takes to do what works.

As optimist and integrationist, it is for the therapist to sustain a broad-based 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.  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 functions, providing focus, direction, and momentum for patient and family.

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 to be 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. 

Interpret and integrate  a complex recovery process

Once your patient has become engaged in treatment, your role is pivotal in keeping that person on track throughout a recovery process that can be lengthy, convoluted, and discouraging. You are responsible for providing the patient and family information, reassurance, and a firm grasp on reality. The patient needs to recognize what point he or she is at in the long journey to recovery, how far he has come, the distance left to go, and what direction he or she will need to take to recover effectively. You and the patient need to anticipate integrate and accommodate to frustrations, regressions and ambivalence strong enough to derail even the most committed recovery at any point along the way.

The circuitous and complex recovery process may sometimes appear to be elusive, and typically feels overwhelming. Your input is the lifeline that keeps the challenges and quality of the effort in the realm of “can do.” It is easy to forget or lose sight of the extent of the challenges that recovery presents when you are as close to the process as is the patient and family. Typically, you as the practitioner will need to function as the collective memory for the patient and the family. In the end, the skill of the practitioner is measured in how clearly the patient grasps his or her OWN pivotal role in bringing about his or her own recovery. It is for the practitioner to empower the patient to recognize success as a function of his or her internal resourcefulness and commitment to health and to understand that personal triumphs can be perpetuated, attained and/or recreated.

Treating these diseases takes fortitude, self-confidence and  courage…the courage to try and to fail, to arouse and resolve anger, to take on, welcome, interpret and use the patient’s resistance as an invaluable learning tool, to enter and positively impact family systems, to follow one’s instincts to augment and interpret prescribed, evidence-based practice. It also takes courage and tenacity to keep on picking oneself up and moving forward, joining with the patient, and in so doing, providing a most compelling model for teaching patients to do the same in doing whatever it takes to achieve desired outcomes.  Treatment of these diseases require practitioners to distinguish patient from disease, advocating for the patient even while battling a disease that resides in his/her very fiber.  Fraught with contradictions and polarities, practitioners treat behaviors in an effort to affect attitudes, thinking and problem-solving; they help patients recover from problems that they may not recognize as pathology or deem to be problematic; they enter family systems even while remaining sufficiently outside of them to sustain objectivity; they offer a recovery process that feels worse to the patient than does disease; they treat families who may be every bit as needy for attention, support and direction as is the identified patient.

There is no specialty that challenges the professional as profoundly and rigorously to use the self with as much courage, insight, sensitivity, intention or decisiveness; there is no specialty that is quite as demanding of the practitioner to be a veteran of professional practice and of life, an integrationist, Machiavellian pragmatist, and activist.  (Likewise, there is hardly a specialty that offers as much personal gratification to the practitioner who is up to the challenge.) 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. 

It is critical for professionals seeking help to be certain that they are not looking in all the wrong places… seeking linear solutions when conceptual ones are needed, seeking theories and concepts when behaviors are required, seeking perfection where healing resides in approximations, seeking control where the best standards for measured growth lie in one’s capacity to solve problems effectively and to roll with life’s punches. Though in some respects elusive, the tools of this trade are actually supremely accessible; in many respects they are disarmingly simple and they are hardly strangers to us. We know them all; we know how to implement them.  We simply have 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, as practitioners need to learn to access our most valuable personal resource of all…ourselves.

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.  Through the quality of their relationship with the patient, 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.