Saturday, December 08, 2007

Practicing with a license

I've given serious thought to going back to school and getting an MSW so I could get licensed as a therapist and work with people who have eating disorders. I've often felt this year like I was practicing without a license--giving therapeutic advice while not being a therapist or having any medical training myself--and wondered if I should get some training.

And I probably will get more training, at some point. But this advice column reminded me that a license doesn't necessarily mean that a) you know what you're talking about, or b) you give good advice.

It's written by someone with an MSW who displays appalling ignorance about eating disorders and the state of treatment. She sounds a lot like the first therapist we saw when my daughter was diagnosed with anorexia. A mother wrote in about her young daughter, who she believes is showing signs of anorexia, and this social worker responded by, first, pooh-poohing the mother's sense of her daughter's health:

Though child anorexia is now being diagnosed in girls as young as six years old, my gut tells me that it’s not the case here. X's weight is stable, and girls suffering from anorexia usually exhibit a rapid and profound weight loss.

Wrong, wrong, wrong. That's what I thought when my daughter got sick, and because she hadn't lost a lot of weight, I figured she couldn't have anorexia. In fact with children and adolescents the issue is often a failure to gain weight rather than a dramatic weight loss. When you weigh only 70 pounds to begin with, it doesn't take much to tip you into a state of malnutrition.

The therapist goes on to say that

Anorexia, which is an eating disorder, is linked to an emotional problem. It is not about food, but rather about feelings. These are often feelings of intense levels of tension and anxiety, or an inability to cope with one’s surroundings. It’s complicated, and it’s certainly not something that most parents would be qualified to “fix.”

Wrong again on every count. As readers of this blog already know, the latest research on eating disorders shows that they are biological illnesses--brain disorders. The head of NIMH has gone on the record saying so. And while they surely are complicated illnesses, there's no one in a better position to help "fix" them than a parent, because the treatment is food. Not psychobabble*. Not circular discussions about feelings. There may be value in therapy, but later on, when the brain is nourished and working properly again.

I guess having a license doesn't mean you know what you're talking about. And not having one doesn't mean you don't. I won't be going back to school but I'm going to keep on trying to educate families and professionals about the realities of eating disorders until the so-called professionals get a clue.

*Apologies to my therapist friends. I'm a big believer in therapy--just not for someone who's acutely malnourished. Food first, talk later.


Rachel said...

I'm actually thinking of switching from a graduate program in history into the social work program. I love journalism, but the opportunity to work with eating disordered patients is also something I'd like to do, or, at least have the proper training on.

As for the advice column, I find it troubling that a so-called health professional would so casually conflate terms that are actually quite different.

It does appear as if the child is suffering from anorexia, because anorexia is a term that denotes a loss of appetite, which sounds to be the case here. It's often pathological in nature, and can occur even when the person wants to gain weight. The term anorexia nervosa is a much more loaded term, characterizing the clinical eating disorder.

And I think it is ethically irresponsible to make a diagnosis or medical recommendation on the basis of a letter.

Harriet said...

Hi Rachel,
Unless you live in a major metropolitan center like New York, I'm not sure I'd recommend journalism as a career. I've been a journalist for 28 years and it's pretty tough to find rewarding work outside of the major publishing hot spots. Social work, on the other hand, and sadly, is always needed. So it might be a good career switch. :-)

Anonymous said...

I do think that ED's may be genetically based, but I don't know if I agree that they are "brain disorders" (or maybe I don't know quite what is meant by this term) -- I cannot agree that an ED is solely a brain disorder and not perpetuated or triggered by ANY environmenal or psychological reason.

One can be predisposed to an ED -- but to get an ED purely accidentally. . . it seems foolish.

I think sometimes they can BE about emotions -- certainly I did relapse into AN to stop feeling everything that was bothering me, from my lack of social life to pressure to do well in my last year of high school. I have copatients who acted similarly.

I probably do have some kind of predisposition to destructive behaviour.

And certainly, I think emotional issues are important to sort out in therapy and often underlie an ED -- if your ED began to ESCAPE these emotions or problems you must learn to CONFRONT these problems w/o symptoms -- and that is the work of therapy. In this aspect it is not about the food.

However, to be able to do this important work it is necessary to be refed and at a minimum BMI of 20. Certainly, therapy is not effective when one is underweight.

just my views -- I don't think it needs to be one way or the other, (psychological or physiological)

Carrie Arnold said...


A brain disease is simply that- a disease that affects the brain. And every illness is a combination of genetics and environment, nature AND nurture. There will be some sort of trigger for an eating disorder (usually "environmental" of some sort) since people aren't born anorexic.

There are some inborn metabolic disorders- such as PKU- where the child will die within 2 years because a basic metabolite cannot be broken down by the body and the toxins build up causing brain damage and death. However, by avoiding the metabolite that can't be broken down (for PKU, that's phenylalanine, an essential amino acid), they will love long, happy, healthy lives. An example of a disease we thought was solely genetic that now has been shown to have environmental effects.

Anorexia is the same, but kind of in the opposite direction. And anorexia isn't all about the food. It is as long as you're underweight or purging or whatever. But the reason that anorexia is 'effective' from a sufferer's standpoint is that it's almost like an anti-anxiety drug. At first, not eating does decrease anxiety by decreasing the serotonin in the brain. Then it spirals out of control. But learning better ways to deal with anxiety has been crucial.

Anonymous said...

Harriet, just move to Australia. The counselling/therapy profession here is unregulated, so you dont need a licence or even any quals to hang out your shingle! Scary really...
Interestingly enough most social workers here dont work as counsellors, it is mainly psychologists and people who have trained specifically in counselling that practice. Social workers tend to work in community service organisations or public institutions like schools, hospitals, the Defence Force etc. I am doing a Masters program in counselling because I would feel like I was a fraud if I practiced without a specific qualifiction, even though I am a qualified social worker.

Unknown said...


Your advice - based on experience and evidence and clear thinking - is better than a bushel of these people who think a degree in anything makes them qualified to dabble in everything.

You have an advantage no set of letters confers: you are right.

Harriet said...

Thanks, Laura. You know that and I know that but those other folks just don't seem to get it sometimes. :-)

Fat Gal, that's appalling! Truly. Ack.

a:), I hope Carrie's explanation was enlightening. The brain is an organ in the body, and its job it so think, so there's always a physiological and psychological component to illnesses like eating disorders. Actually I think physiological/psychological is a false dichotomy. The act of thinking grows out of physiology. We are learning all the time how the body affects the mind (and vice versa).