by Paula Levine, Ph.D.

Whether a patient suffers from anorexia, the "self-starvation syndrome," or bulimia, the "binge-purge syndrome," or the binge-eating disorder, a new classification for what is often referred to as "compulsive overeating," all three disorders are difficult to treat and require time, patience and expertise to achieve a full recovery. The eating disorders professional, who actually treats the individual with an eating disorder, should be a licensed mental health professional with a degree in either psychology, psychiatry, social work, mental health counseling, or marriage and family therapy. Further training through workshops, conferences and certification programs is essential in order to become a true specialist in this area.

Ninety percent of eating-disorder patients are females ranging in age from 10 to 60, with the majority being girls in their teens and women in their 20s. The incidence of anorexia is 1 in 200 girls, and the incidence of bulimia, particularly among college students, ranges from 3 to 10 percent. Imagine a college dorm or sorority house in which every 10th girl binges and purges on a regular basis! Unfortunately, while the prevalence of eating disorders does not appear to be decreasing, the age of onset appears to be going down. For example, girls are starting to experiment with dieting, bingeing, purging, laxatives and fasting at younger ages than ever before.

In order to demonstrate to the patient that her struggle with anorexia or bulimia is being heard and understood, eating disorder professionals really have to "talk the talk and walk the walk." Does that mean they all have to struggle with an eating disorder themselves? No, and I, personally, have not. But when I say, "I know it was that fourth slice of pizza that triggered the purge," or "Of course you fasted the next day to make up for last night's binge," or "I'll bet you thought that losing five pounds would help you run faster," my patients know that I have entered their world and am capable of speaking their language.

The most important role of the eating disorders professional is to relate to the patient in a way that convinces her that her feelings and behaviors are not being judged, belittled, diminished or disregarded. Enough people in her life have already told her "Just start forcing yourself to eat," or "Put a lock on the refrigerator door," or "Throw out your fashion magazines," or "Just accept yourself and buy bigger clothes." The therapist assures the patient that treatment will not consist of random suggestions which will only lead to feelings of failure and frustration. Rather, it will be a well-thought-out treatment plan, designed by both parties and based on changes the patient believes she is capable of making in small, manageable steps that will likely lead to success. The therapist might say to the bulimic patient, "Do you think you're ready to purge one less time per evening, or eat one meal per day and keep it down?" To the anorexic patient she might suggest that a meal out with her family in a restaurant is a challenge to her food rituals at home, or a day off per week from her over-exercising routine.

In addition to personalized behavioral tasks, often given in the form of homework assignments, a great deal of the therapeutic work consists of challenging the distorted thinking patterns that underlie the eating disordered behaviors. This approach -- attending not only to behaviors, but also to underlying belief systems -- is called cognitive-behavioral therapy, widely recognized as the most effective therapy for the treatment of eating disorders. However, even more worthy of attention than the patient's thoughts and behaviors are her feelings -- feelings of depression, anger, self-loathing, guilt, shame and low self-esteem -- all of which may have contributed to the development of the eating disorder in the first place, and are still maintaining it.

In focusing on developing healthy self-esteem and a positive body image, patients are encouraged to identify, express and examine the range of their emotions, many of which they have been repressing for years. If depression is getting in the way of treatment, antidepressant medication is recommended. Because eating disorders are such secretive illnesses, interpersonal relationships have usually suffered, so patients are encouraged to explore and strengthen relationships and learn to depend on people, rather than food or calorie-counting, for comfort, self-control and support.

Another important role of the eating disorders professional is that of team leader. The "smart" psychotherapist surrounds herself with a team that consists of a physician, psychiatrist (if medication is indicated), nutritionist and, in some cases, a family therapist to work either with the whole family or with the parents of the youth in treatment. The school guidance counselor and/or athletic coach should also be included on the team as needed. Communication is extremely necessary, particularly if there is a medical crisis such as sudden weight loss and the need for hospitalization, or a crisis at school because Suzy faints on the soccer field or her best friend finds out about her bulimia.

Finally, the eating disorders professional has a role to play in the area of prevention. I am past president of and currently on the board of Eating Disorders Awareness and Prevention (EDAP), a national nonprofit organization dedicated to increasing the awareness and prevention of eating disorders. In this capacity, I offer my time, energy and expertise, as do many of my colleagues, conducting workshops and seminars across the country in order to educate young girls, parents, educators and other mental health professionals about the following:

• Precursors to eating disorders.
• Populations at risk.
• Ways to detect signs and symptoms as early as possible.
• Variety of treatments available.

The attitudes in our society must be challenged and changed so that someday we will actually be able to prevent new cases of eating disorders from occurring. Until then, I will continue to be a confidante, a friend, a guide and a partner to my patients on their road to recovery.

Paula Levine is the director of both Anorexia and Bulimia Resource Center and Agoraphobia Resource Center in Coral Gables, Fla. She is a certified eating disorders specialist, and is certified by the American Society for Clinical Hypnosis. She is well-known for her innovative work with eating disorders, and speaks regularly at national and local conferences.