The case being analyzed this week deals with a 26-year-old female client who is believed to be suffering from the eating disorder bulimia nervosa. The client, Rita, tries to control her weight through a vicious cycle of fasting and bingeing and purging (vomiting). Rita’s bingeing and purging rituals are becoming ever-more out of control, with Rita bingeing approximately two to three times a week, which is generally followed by a purge session. Moreover, even on the days Rita is fasting, she feels the pressing urge to purge anytime she consumes food. After approximately 6 months of bingeing, Rita had gradually gained 10 pounds, which began to pressure her to think about resorting to more extreme measures to reach her self-proclaimed ideal weight. Thus, she sought help through a behavior therapy program and was referred to Dr. Heston, a psychologist who has know-how and proficiency in the treatment of eating disorders (Gorenstein & Comer, 2015).
Dr. Heston implements cognitive and behavioral theoretical orientations through the utilization of cognitive-behavioral therapy (CBT). CBT is embedded in each of the interventions proposed by Dr. Heston, which include: (1) Educating Rita about the etiology of eating disorders, (2) Requiring Rita read psychoeducational handouts and treatment manuals for homework, (3) Requiring that Rita monitor her food consumption via a nutritional journal; and (4) Teaching Rita how to identify dysfunctional thinking and develop more healthy cognitions and coping skills (Moten, 2014). Each of these interventions endeavors to change both distorted cognitive attitudes about weight and other thinking patterns, as well as unhealthy behavioral eating practices.
The cognitive behavioral model of the maintenance of bulimia nervosa (BN) is due to “a vicious feedback cycle of interrelated cognitions and behaviors associated with low self-esteem, extreme concerns about shape and weight, strict dieting, binge eating and self-induced vomiting” (Braun, 2009, p. 208). CBT is designed to help patients reduce the urge to binge via structuring food consumption in a fashion that keeps behavioral and physical deficiency to a modicum. Additionally, measures are developed to prevent binges should the impulse surface. Finally, it is generally helpful to work with patients in becoming less engrossed with weight and eating concerns (Gorenstein & Comer, 2015).
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s part of Rita’s ongoing treatment, Dr. Heston requested that Rita start keeping track of her eating habits, as well as any other related stresses. Dr. Heston informed Rita that she could choose a method that she felt most comfortable with. Rita expressed some strong reservations and hesitancy toward the record keeping, revealing that she had previously tried such a method but did not find it helpful as it had reportedly increased the focus on her eating (Gorenstein & Comer, 2015). As Halmi (2013) explicates, the treatment of eating disorders is a complex course and often times a quite difficult journey, as treatment resistance is a frequent characteristic and aspect involved in the process. Patients with eating disorders may be resistant to treatment due to their conditioned learning via their eating/noneating, bingeing/purging rituals. Moreover, “trait-related multigenic and neurobiological vulnerability when modulated by environmental risk factors” (Halmi, 2013, p. 8) have been revealed to effect and impact the manifestation and growth of eating disorders and might correspondingly promote treatment resistance.
Additionally, while Dr. Heston has a great start in terms of treatment interventions, it would be most beneficial to Rita if she also met with a psychiatrist and nutritionist regularly. The reason behind this sort of recommendation is that the more support, encouragement, and knowledge Rita gains from those with an expertise in leading healthy lifestyles, the more able she will become to make healthy choices for herself in the long-run, at least in theory. As maintained by DeJesse and Zelman (2013), mental health professionals and nutritionists attend to two major features of eating disorders: primary mental/emotional concerns and the patient’s rapport with food, “and their successful collaboration is of enormous importance” (p. 186). However, while this collaboration is beneficial and quite frankly necessary, it is also not without its complications and limitations.
When there is a collaboration among different health care providers, there comes the unique challenge of integrating diverse treatment attitudes, methodologies, training, goals, overall practices, et cetera (DeJesse & Zelman, 2013) in such a way that is beneficial and conducive to the patient and sometimes their families. Ultimately, it is imperative to keep in mind the patient’s overall well-being. Some challenges that have the potential to be encountered in a collaborative relationship among health care providers include: encroachment, putting a patient in the middle, lack of expertise, inharmonious strategies, and lack of communication (DeJesse & Zelman, 2013). Additionally, there are some ethical issues Dr. Heston should consider when working collaboratively with other professionals. First and foremost, one of the most basic principles of psychologists, as well as other healthcare providers, is do no harm. This stipulation is rather broad, but includes avoiding harming patients even in the face of personal, professional, social, and any other sort of major conflict (APA, 2010). Moreover, standard 3.09 – Cooperating with other professionals should be upheld to ensure the patient’s needs are served efficaciously and suitably. There are also issues with maintaining confidentiality and privacy, along with discussing its limitations and ensuring that anything that is disclosed between the professionals is first approved by the client. Overall, the patient’s quality of care and general well-being is of the utmost importance, something that should be established at the outset of the collaborative relationship.
Once the interventions were established, it was time for Rita to begin her course of treatment. As with most cases, Rita was initially hesitant when it came to Dr. Heston’s suggestions. In particular, Rita was unsure about weighing herself only once a week, eating lunch every day, making appropriate meal modifications that required her to consume more food, and scheduling activities for herself several nights a week (Gorenstein & Comer, 2015). Nevertheless, Rita followed each of the proposed suggestions and as time progressed, each session illustrated an improvement in the number and frequency of Rita’s binges and purges. Still, Rita had this undeniable fear of gaining weight whenever she would binge on foods she labeled as bad. Because of this fear, Dr. Heston began to use a behavioral technique, for example, she had Rita eat the foods she labeled as bad during their therapy sessions, in an effort to get her to face her fears of gaining weight, and to illustrate that eating these bad foods was actually rather harmless when it came to Rita’s weight. This point was further explored and supported when Rita was required to weigh herself before and after eating the bad food, wherein Rita discovered that she had not gained any weight from the food she had consumed even though she had stated she felt like she would gain at least “2 pounds” from eating a single cookie (Gorenstein & Comer, 2015). Later sessions included more behavioral exercises as well as exercises of cognitive reinterpretation to assist Rita in eliminating her fears and avoidance of a number of activities. Such approaches echo the CBT approach to treatment, which has been shown to be most efficacious as it focuses largely on exposure, behavioral change, cognitive reconstructing, recording, and personalized construction and presentation (Jones & Clausen, 2013; Waller, et al., 2014). Overall, Dr. Heston’s interventions were highly effective in helping Rita overcome and successfully manage her symptoms and tendencies. In fact, six months following their final session, Rita called and informed Dr. Heston that she was successfully maintaining her progress and had only had one purging slipup, but that was about a month after their sessions had ended (Gorenstein & Comer, 2015). From that point on, Rita has efficaciously sustained more healthy eating habits and appearance outlooks.
Finally, and in conclusion, three additional treatment interventions that would be applicable to this case would include: group CBT sessions at least once a month, dialectical behavior therapy (DBT), and nutritional counseling. Group psychotherapy sessions would be beneficial to Rita in the sense that it would provide her with another safe environment conducive to self-admission and honest discussions about Rita’s struggles with her secretive condition. Moreover, it would help diminish the sense of isolation that Rita and so many others struggling with this disorder often feel (Jones & Clausen, 2013). DBT would be a great additional intervention in that Rita seems to struggle with emotional regulation, subjective stress, and interpersonal and social skills, which all play a key role in the perpetuation of maladaptive behavior (Lenz, Taylor, Fleming, & Serman, 2014). Thus, DBT would be a great intervention to help Rita develop more accommodative behaviors. Finally, nutritional counseling would help Rita learn how to make smarter food selections, selections that are neither robust nor restrictive. This is an important part in overcoming the bingeing and purging tendencies that Rita struggles with. Nutritional counseling will enable Rita to eat sufficiently enough to meet the body’s daily nutritional needs, develop a manageable and balanced relationship with food that is devoid of distorted and negative cognitions about herself, and learn to listen and trust her body to tell her when it is hungry and/or full. Such benefits will ultimately help Rita promote her recovery process.
References
American Psychological Association (2010). Ethical principles of psychologists and code of conduct: Including 2010 and 2016 amendments. Retrieved from https://www.apa.org/ethics/code/index.aspx
Braun, D. L. (2009). Cognitive behavioral therapy for bulimia nervosa. Retrieved from https://devrabraunmd.files.wordpress.com/2009/12/openaccess-program-file-fr9.pdf
DeJesse, L. D., & Zelman, D. C. (2013). Promoting optimal collaboration between mental health providers and nutritionists in the treatment of eating disorders. Eating Disorders, 21(3), 185-205. doi:10.1080/10640266.2013.779173
Gorenstein, E. E., & Comer, R. J. (2015). Case studies in abnormal psychology (2nd Ed.). New York, NY: Worth Publishers.
Halmi, K. A. (2013). Perplexities of treatment resistance in eating disorders. BMC Psychiatry, 13(1), 1-12. doi:10.1186/1471-244X-13-292
Jones, A., & Clausen, L. (2013). The efficacy of a brief group cbt program in treating patients diagnosed with bulimia nervosa: A brief report. International Journal of Eating Disorders, 46(6), 560-562. doi:10.1002/eat.22120
Lenz, A. S., Taylor, R., Fleming, M., & Serman, N. (2014). Effectiveness of dialectical behavior therapy for treating eating disorders. Journal of Counseling & Development, 92(1), 26-35. doi:10.1002/j.1556-6676.2014.00127.x
Moten, S. (2014). PSY650 Week three treatment plan📷📷 [PDF]. College of Health. Ashford University: San Diego CA.
Waller, G., Gray, E., Hinrichsen, H., Mountford, V., Lawson, R., & Patient, E. (2014). Cognitive-behavioral therapy for bulimia nervosa and atypical bulimic nervosa: Effectiveness in clinical settings. International Journal of Eating Disorders, 47(1), 13-17. doi:10.1002/eat.22181
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