The Treating Psychotherapist and the Nutritional Therapist:

Roles and the Importance of a Division of Labor

By Jacqueline Reily, LMSW

Eating disorders serve a purpose. They are a cultivated set of internal and external processes that protect, remove and distract the patient from intolerable feelings. The eating disorder carries the patient away as it offers a safe haven and peace in an otherwise tumultuous and unskilled inner world. The patient often has elaborate systems of thought and rituals surrounding food that takes up time and that is in some maladaptive way, soothing as well as punitive. The internal language and words around the eating disorder are often simplistic, formulaic, predictable and punishing. They are an internalized framework the individual has come to trust and in some ways to love as well as to loathe. This world is characterized by counting calories, checking one’s weight and body shape, planning perfect eating, researching weight loss strategies, and nutritional facts. Often a patient is quite well versed in the details of nutrition and weight loss. They may be emotionally regressed, given to shame and utterly lacking in ability to accept any other mode, outside of the distorting filter of the eating disorder, for experiencing emotions. The eating disorder also reinforces a sense of being separate and undeserving of a normal life, while keeping the patient fearful that their secret will be discovered.

At times, a person suffering with anorexia nervosa, bulimia nervosa, disordered eating or binge eating disorder may use a team approach for their recovery. This article addresses a bit of why an experienced nutritional therapist and a psychotherapist work so well together. Especially with regard to the distorted belief that emotional suffering can be relieved if only one could achieve a perfect body shape or perfect eating plan.

A person suffering with an eating disorder will often carry an enduring fantasy that all troubled feelings will slip away when they find the right eating plan, achieve the right body shape, or desired number on the scale. The nutritional therapist helps them get the right answers about food and this correct information challenges the distortions of the eating disorder. These answers, however, are never perfect and do not engage enough of the psychological needs of the patient. The patient may insist that their eating issues are merely behaviorally based bad habits and that they need strategies to let go of these maladaptive practices. Framing the eating disorder in such a simplistic fashion is just further avoidance of a fragile emotional life and a protection of the maladaptive emotion blocking effect of the eating disorder. The nutritionist provides the concrete behaviorally based tools to start the work of recovery while the psychotherapist helps foster an emerging inner world and emotional language retrieved from the ruins of the eating disorder.

The obsessional relationship with food must be interrupted and replaced by the relationship that the therapist and patient craft together in the space of the therapeutic process where it is safe to approach the feelings underneath the eating disorder. That relationship becomes a model for relationships in the outside world as the patient is encouraged to take risks toward the development of normal attachment in their everyday lives. The relationship between the analyst and the patient becomes a bond that undermines the pathological process of the eating disorder.

The registered dietitian, skilled in the treatment of eating disorders, will be able to field all the patient’s questions and redirect their distortions to a healthy and truthful understanding of nutrition. By getting the correct information the patient is one step further toward letting go of the incorrect story of the eating disorder. The patient is also invariably terrified of eating normally, of taking in nurturing and nourishment on a physical as well as emotional plane. Accepting the imperfections in the world and the reduced level of control a patient will have in an adaptive emotional relationship to the world, takes time.

If the therapist is unaware of this dynamic they can make the mistake of collaborating with the illness and waste precious treatment time and, unwittingly, assist in further embedding and validating the eating disorder. Attachment subverts the eating disorder through the relationship to the therapist and the experience of the eating disorder in a space of honesty and safety where previously, there was isolation and distortion.

Boundaries are crossed when the nutritional therapist engages in the emotional processing aspect of treatment. Likewise, boundaries are crossed when the therapist strays into the arena of behaviorally based nutritional direction. When the therapist engages in this area incorrect information is generated and the message is validated that the eating disorder is a problem of eating strategy and not of underlying unresolved emotional states. Congruently, the dietician, because they are engaged in a predominantly nutritionally based treatment, cannot provide the safety that the patient needs to proceed along the very brave path of letting their emotional world unfold.

The team approach is extremely helpful because it immediately addresses the often critical issue of restoring nutritional integrity. At the same time, the psychotherapy becomes a place of emotional work, a place where the sufferer can explore the meaning behind their eating disorder and leave aside the notion that all answers come from perfection of eating and body shape.