Nutrition Counseling in the Treatment of Eating Disorders

MARCIA HEREIN: Nutrition Counseling in the Treatment of Eating Disorders. Brunner-Routledge, New York, 2003, 284 pp., $34.95, ISBN 1-58391-031-X. In contemporary postindustrial societies, eating disorders are common, complex psychiatric illnesses with serious medical, nutritional, and psychological consequences. While the optimal treatment of bulimia nervosa, anorexia nervosa, and binge-eating disorder remains a matter of clinical controversy, there is widespread consensus for an approach that combines long-term psychotherapy, medical supervision, and nutrition counseling. Collaboration among psychotherapist, primary physician, and dietitian requires mutual understanding of each professional discipline as it fits into the patient's overall treatment. For many psychotherapists, even some with considerable experience in treating eating-disordered patients, the exact nature and scope of the dietitian's therapeutic role remains somewhat obscure. What makes nutrition counseling useful for anorexic and bulimic patients? How does it resemble and differ from dynamic psychotherapy? How do clinicians negotiate the intersections between these complementary treatments? In Nutrition Counseling in the Treatment of Eating Disorders, Dr. Marcia Herrin, an experienced dietitian specializing in nutritional counseling of eating-disordered patients, presents a comprehensive description of her discipline. As one would expect, the dietitian's approach to nutrition counseling is primarily behavioral: eating-disordered patients suffer from abnormal food practices that must change. For the anorexic patient, change includes weight restoration; for the bulimic patient, eating patterns that provoke binge-purge cycles must change. Herrin defines the territory of the nutrition counselor as promoting behavioral change with a goal of healthier patterns of eating. The dietitian's more familiar role as expert educator for patients with medical conditions like diabetes, liver disease, or renal failure requires expansion to address the complex predicaments regarding food, experienced by most patients with eating disorders. By definition, patients with anorexia nervosa, bulimia nervosa. and binge-eating disorder are ensnared in their unhealthy food behaviors. Layers of resistance and fear offset their motivation for change. As a result, the dietitian's role is a complicated one. Most of Herrin's volume is devoted to presentations of motivational, relational, educational, and therapeutic techniques to help overcome patients' resistances to change. This process begins with the establishment of a trusting, respectful professional relationship and continues throughout the incremental course of treatment. While the dietitian always remains focused on the specific goals of healthy behavioral change, as evidenced by improving nutritional state and normalizing weight, much of the work is interpersonal. The dietitian helps find common ground in what could easily become an adversarial struggle. While the need to recover is assumed from the outset, each step in recovery is negotiated as a compromise between what might be nutritionally optimal and what is currently possible given the patient's fears and resistances. …