The “T” Word

Posted on by

“You run into that more than I do. All of my patients are already in therapy.”

That is how Joanne responded when I suggested that she write a feature about the challenge of helping resistant patients in need of therapy to agree to go. Apparently, the responsibility of writing about the topic then falls on me, and appropriately so, I suppose, for I do run into this issue quite often on my side of our practice.

Joanne rarely runs into this dilemma because she focuses exclusively on eating disorders, and by the time a patient makes their way to her, the importance of a complete treatment team – a dietitian, a physician, and yes, a therapist – has usually been explained and emphasized to them at some point already.

In contrast, while eating disorders are similarly my area of specialization, I also help people with other conditions, such as high cholesterol and hypertension. As such, I tend to attract patients who view – or want to view – their challenges as superficial food issues even if it quickly becomes apparent to me that something deeper is at play.

That brings us to a critical juncture in our work and often a difficult conversation. How do we emphasize the importance of therapy while remaining sensitive to the reality that we live in a society that stigmatizes mental health issues?

Well, we do just that. We talk about the upsides of therapy as well as the patient’s thoughts, questions, and concerns, including any hesitations they might have. Oftentimes we also talk about the stigma because I think it is important to bring out into the open the reality that a therapy referral comes with a connotation that would not arise if I were suggesting someone meet with pretty much any other kind of specialist.

Sometimes patients are hesitant to disclose their true reasons for not wanting to go to therapy, or maybe they have trouble putting their fingers on what their reasons are, but they know they do not want to go. “It is not worth the time,” “I do not hate myself,” and “I have friends I can talk to” are some of the superficial reasons patients have told me. Time, trust, and continued conversation are sometimes necessary for us to get to the point of having a candid discussion about whatever their hesitations really are.

A common sentiment I hear is, “I think I want to start with just a dietitian.” Earlier in my career, I had a peer supervision leader who refused to work with a patient with an eating disorder unless they were also in therapy, a policy that I then adopted. Eating disorders are mental health issues that play out through eating behaviors, so while they affect nutrition, they are not directly nutrition issues. The dietitian’s roles are to provide nutrition support (if applicable) and to help the patient form a new and healthier relationship with food as the disorder recedes. However, because eating disorders are mental health issues, the bulk of the recovery does not happen with a dietitian, but rather with a therapist. Without this key member of the treatment team, the patient’s chances of recovery drop so dramatically that some dietitians, including my peer supervision leader, feel it is unethical to work with someone who refuses therapy.

In the last few years, as a result of conversations I have had with other colleagues, I have reversed course. The rationale is that if I terminate my work with a patient who refuses therapy, then they are left with nobody to help them, but if I continue working with them, then at least they have me in the meantime, and, hopefully, they will become more open to the idea of therapy as time goes on.

As dietitians continue to debate this issue, my own ambivalence oscillates from one side to the other and back again, and I have no idea what my policies will be in this regard down the road. What I do know, and what dietitians who specialize in treating eating disorders agree on, is that therapy is essential for recovery.

Therapy can also be immensely helpful for some patients without eating disorders, too. One of the most interesting aspects of nutrition work – but also one of its greatest challenges – is the wide array of factors that influence the decisions we make regarding what, when, and how much to eat. Many examples, such as low self-esteem or a poor relationship with a close family member, can significantly affect eating behaviors, yet are largely beyond my expertise to treat alone. The boundary of my scope of practice bleeds into that of mental health professionals, who can effectively address these deeper issues and free people up to form healthier relationships with food.


Posted on by

At a large family gathering over the weekend, a distant relative asked me about my work. Upon hearing that I am a dietitian, he smiled, leaned in, and asked me one of the most common initial questions that dietitians field, “So, do you practice what you preach?”

Whenever this question comes my way, I experiment with different permutations and phrasings of the same core truth in order to see which version best resonates with people. In this instance, I told him that what I “preach” might not be what he imagines, and that in reality a large chunk of what I do involves helping people to listen to and honor their internal cues regarding hunger, fullness, and food cravings.

His eyes wandered elsewhere as I spoke, and I could tell that this version of my answer was most definitely not resonating with him. When I finished, he reflected back to me, “That sounds like psychology.” He is not alone in his confusion, as other people have reacted similarly upon hearing a summary of intuitive eating. However, reconsider my answer within the framework of the following examples.

When a diabetes educator discusses the symptoms of low blood sugar with his or her patient, is that psychology?

When a physical therapist instructs a patient on how to modify an exercise in response to pain or discomfort, is that psychology?

When a primary care physician listens to his or her patient recount the side effects he or she experienced on a particular medication, is that psychology?

When a personal trainer talks with his or her client about the difference between the temporary discomfort that sometimes accompanies exertion and warning signs of injury, is that psychology?

Of course not, none of these examples are psychology; they are just examples of various discussions that take place between patients and practitioners regarding the feedback that our bodies give us in particular situations.

Yet when a dietitian engages in a similar discussion with a patient, whoa, suddenly it is seen as psychology. What does it say about how disconnected our culture teaches us to be from our internal signals regarding eating that an approach that encourages us to pay attention to said signals triggers connotations of therapy?

Dietitians are not psychologists, psychiatrists, or social workers (Well, some are, but the vast majority do not hold such a license in conjunction with their dietetic credentials.) and we know our professional boundaries. Discussions of said internal signals are not only within the realm of our work, they are critical to its success.

Just as my relative expected a more concrete and specific answer that would have put some label on my personal style of eating, new patients often expect that a similar external structure, such as a meal plan or a calorie recommendation, will drive their care. Nutrition is not that simple. In fact, long-term success often hinges on paying less attention to external cues regarding what and how much to eat and putting more focus on the internal signals that our bodies give us. Does that sound like psychology to you?