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Meet the Author: Eating Disorders Expert Abigail Natenshon

Abigail Natenshon. Photo courtesy of

Abigail Natenshon. Photo courtesy of

Social worker Abigail Natenshon, MA LCSW, GCFP, has treating eating disorders among families and individuals for more than 40 years. Treating anorexia, bulimia and other eating disorders is extremlely difficult, she found. And social workers and other mental health experts get little specialized training on eating disorders.

That is why Natenshon decided to write “Doing What Works: an Integrative System for the Treatment of Eating Disorders from Diagnosis to Recovery” (NASW Press, 2009). talked to Natenshon about the prevalence of eating disorders and her book.

Q: Tell us more about yourself.  Why did you decide to become a social worker and where did you attend college?

Natenshon: Having read “The Other America: by Michael Harrington in college, my concern for poverty-stricken minority populations piqued my interest in pursuing a career in social change and community organization. I received my masters degree from the University of Chicago in 1970.

Q: When did you first begin to notice eating disorders among clients?

Natenshon: Having worked in community mental centers for many years following graduate school, I discovered that my first love was working with families and groups. After beginning a private practice years later and having too few of such cases, I contacted my local hospital seeking additional employment several hours per week treating families and groups. They put me to work in their Eating Disorders Unit, where I was immediately hooked, feeling so moved by the dire emotional and physical consequences of these disorders on the lives of patients and their families, as well as by the transformational outcomes attainable through effective treatment.  I have so enjoyed my relationships with my eating disordered patients, whom I find to be bright, personable, quality human beings. By the early 1980’s, I had committed myself to an eating disorder specialty and to contributing to the development of the field. My first book, “When Your Child Has an Eating Disorder: a Step-by-Step Workbook for Parent and Other Caregivers,” was the pioneering book in the field to advocate for the enlightened and substantive involvement of parents and families in the eating disorder treatment process.

Q: Are eating disorders prevalent?Are women more affected than men?

Natenshon: Eating disorders have been on the rise in all industrialized nations and societies since the 1950’s and the eating disorder diagnosis in men has doubled in the past decades. The actual occurrence of clinical eating disorders is rare, (only one to four percent of the general population). Yet  in our  fast-paced, weight- and fitness-conscious society, the prevalence of disordered eating behaviors such as skipping meals, over-eating in response to food restriction, and engaging in excessive exercise for the sole purpose of weight loss has become widespread. This has triggered the onset of clinical eating disorders in individuals with a genetic propensity for these diseases. It is interesting to note that only one out of three people with clinical eating disorders get treatment for these most lethal of all the mental health disorders.

Q: Are eating disorders hard to treat?

Natenshon: Eating disorders are highly difficult to treat, which is precisely the reason that I wrote my second book, “Doing What Works: an Integrative System for the Treatment of Eating Disorders from Diagnosis to Recovery,” as a guide for clinicians. Graduate schools of medicine and mental health typically do not offer specialized courses in eating disorder case management in the mistaken belief that general courses in psychotherapy provide sufficient preparation for this treatment. They do not.

Though many of the skills learned in generic practice do apply to eating disorder treatment, the unique and challenging demands of eating disorder treatment are pivotal and can be life-saving. Eating disorder treatment requires special expertise. Here’s a list of reasons why:

  • These mental health disorders are so lethal, putting patients at physiological and emotional risk;
  • Eating disordered patients typically come to treatment with strong fears and resistance to healing from their disorder;
  • Therapists, even while seeking to gain the trust of patients, are required to demand changes that feel threatening to the patient, such as weight restoration to save lives and enhance the therapy process;
  • There are so many misconceptions about these disorders, what they do, where they come from, and how they heal;
  • Inevitably, the process of recovery feels worse than the disease;
  • Despite the fact that eating disorders occur within the family system and recovery happens at home, parents are all too often excluded from treatment;
  • Evidence-based, manualized treatment techniques that are considered “best practice” fail to accept that one of the most significant treatment tools proven to achieve a timely and sustainable recovery is an empathic and mindful therapeutic relationship between therapist, patient and family.
Book cover

Book cover

Q: Are eating disorders a reflection of our society’s obsession with being slender?

Natenshon: The question about societal influences is an important one because it raises the issue of eating disorder origins, about which there are many misconceptions. Societal norms can become a triggering factor in the onset of a clinical eating disorder, but not unless the individual was born with a genetic susceptibility to develop an eating disorder. Gene clusters that result in the onset of eating disorders may include genes that carry anxiety and depression, familial eating disorders, addictions, (though eating disorders are not addictions and are completely curable), perfectionist temperament, etc. With their origins in nature as well as nurture, eating disorders are essentially biological disorders, based as they are in genetics and brain chemistries, though triggered by environmental factors. It has been said, “Genetics loads the gun and the environment pulls the trigger.”

Q: The book contains various ways to treat eating disorders. Does that means some methods work better than others, depending on the individual?

Natenshon: Eating disorders are highly integrative disorders, affecting mental and physical health, nutrition, brain chemistries, mood, cognitive acuity, personality and sociability. Optimized healing happens through treatment techniques that are also integrative, to match the nature of the disorder. Though research has shown Cognitive Behavioral Therapy (CBT) to be the best practice in the treatment of clinical eating disorders, there has also been scientifically based evidence about the importance of a mindful, empathic therapist/patient relationship in facilitating mutual trust, motivation, and the ultimate return of the exiled self; the restoration of the authentic self is the benchmark of eating disorder recovery.

Eating disorders are disorders of the brain; integrative and effective treatment needs to direct itself to the ever-plastic brain within the afflicted individual. Certain distinct characteristics defining the anorexic personality and the nature of sensory, cognitive and perceptual processes of anorexia have been shown to be trait characteristics, their origins existing within the structure and function the brain. In addition, brain scans have proven that within the therapeutic relationship, empathic resonance is stimulated by a mindful connection between the patient’s and therapist’s right-brain hemispheres, modeling and facilitating the patient’s own capacity for self-regulation.

In attending to the task of healing the patient, brain, eating disorder and body image disturbances, certain non-traditional adjunctive treatment techniques can make a significant contribution in healing the cranium-based ‘mindself,’ which learns ‘from the top down’ through mediated forms of cognitive restructuring; as well as the ‘bodyself’ or ‘the self that is embodied’, which learns ‘from the bottom up,’ through various forms of movement-based somatic education. These would include the Feldenkrais Method, yoga, dance therapy, etc.

Every eating disorder is like a thumbprint, its uniqueness determined by developmental strengths and weaknesses that individual patients bring to the treatment experience; by the quality and nature of the support and resources available to the patient through parents and professional caregiving, and by the therapist’s skillful, facile and empathic use of self within the treatment experience.  An integrative team of professionals, including the individual and family therapist, medical doctor, psychopharmacologist, nutritionist, (and potentially, somatic educator) needs to collaborate in bringing various forms of expertise to the treatment experience, meeting the diverse needs of these disorders and patients, bringing the patient ever closer to himself/herself.

Q: You have said you are not afraid to show your affection and authentic self when treating clients? How does this help?

Natenshon: There is a widespread misconception in professional circles that any demonstration of warmth, affection, or genuine caring on the part of the therapist indicates boundarylessness and “friendship.”  Quite the contrary, I believe that a relationship built on warmth and caring not only stimulates the patient’s trust in the therapist, therapy relationship, and treatment process but ultimately raises the patient’s self-trust, self-nurturing and autonomy, all of which mark recovery. The patient’s opportunity for emotional growth and development, experienced through a boundaried, but intimate and healthy treatment relationship, is the best practice ground for the patient to experience and initiate healthy relationships in all life spheres. As an eating disorder becomes entrenched, it essentially displaces or exiles the victim’s own authentic personality and self. In demonstrating their own authenticity, therapists become pivotal role models of fearless honesty, sound problem solving, and most of all, of courageous and genuine investment in the other; the ever-deepening human connection ultimately leads to the patient’s sense of self, healing and empowerment. Like good parents, by establishing boundaried affection and mutual trust, therapists establish the authority and traction they need to set appropriate limits and boundaries, to create realistic demands, and demonstrate ‘tough love’ in preparing the patient ultimately to leave the treatment nest, capable of self-support and self-nurturance, with the option to return to treatment on an ad hoc basis.

NASW Press offers a variety of publications of interest to social workers, including books, journals, and brochures. And to learn more about how social workers such as Abigail Natenshon help clients overcome mental health challenges visit the National Association of Social Workers’ “Help Starts Here” Mind and Spirit website.


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