When working with people with eating disorders, it is important to shift paradigms to one of resourcefulness vs. sickness
The therapeutic relationship determines clients willingness to openly discuss and explore behavior patterns, consider altering eating behavior and disclose accurate information.
You can improve motivation by creating mutually agreeable goals for treatment, and understanding and tipping the motivational balance regarding the cost/benefit of the current behaviors and attitudes such as
~ Fear of fat vs. desire to be healthy
~ Social pressures vs. desire to change
~ Sense of self-efficacy vs. powerlessness
When assessing strengths, it is important to ask
What kind and type of therapy did you have in treating your eating disorder
What parts of your treatment were helpful, if any?
What interventions were helpful and under what circumstances
Do you believe you have any other issues such as depression or anxiety?
What interventions or strategies that were helpful in the past might be helpful now?
Explore Exceptions When has what worked and why? Under what conditions has each activity produced an exception and failed to produce an exception
Use scaling questions to help the client stop viewing things in terms of dichotomies
Have the client rate on a scale of 1-5 (It is helpful to give verbal anchors) and then explain why she chose her number.
~ How anxious does it make you to think about…
~ How accepted do you feel by…
~ How helpful was therapy/x-intervention in the past?
~ How often have you been successful at going a day without bingeing?
~ Scaling can help therapists highlight ignored exceptions and positives
Feedback messages/summary should highlight positive actions or events, restate of the client’s goal (Ex. “You want to get control of your eating so you don’t feel you have to purge to maintain your weight.”) and identify next steps, including homework assignments.
Goals of the First Session
Attend to present and future with little attention paid to the past
Explore a problem free future
Enhance exceptions and previous solution patterns
Provide feedback and therapeutic compliments
Second session and beyond
Separate the person from the problem
Stay focused on client strengths and resources
Don’t take a position regarding the client’s situation
Constantly check in to see if the client’s specific goals have changed. (i.e. I want to be happy, but have realized that losing weight won’t make me happy it is…)
Continually evaluate the client's stage of change…watch for yes buts which indicate…
Explain the necessity to focus on small, realistic goals one at a time
Develop a plan to tolerate behavioral and attitudinal slips or relapses
Must be concrete and practical
Must be presented as a way to create an “exception” related to a client’s identified goal. That is, how can creating this food plan help you achieve your goal (and prevent the behavior you are trying to eliminate).
Generally the food plan will be done in conjunction with a Registered Dietician or a physician.
Clients should also maintain a self monitoring journal in the form of a table asking…
What did you eat?
How much did you eat?
Were you hungry? If not, what prompted your eating?
Were you craving sweet/salty/spicy or a specific food?
How did you feel after you ate?
Did you purge?
If yes, how did you feel afterwards and what could you do differently next time?
If no, how did you feel afterwards and what did you do to prevent the purge?
What information/exceptions can you derive from this type of table?
Remember that many clients coming in are terrified of gaining weight and eating certain “forbidden foods.” In order to help them start making progress toward their goals it may be helpful to address seemingly unrelated concerns such as their relationship or their depression. It is likely that these issues which seem out of control may be contributing to the distress that is maintaining the eating disordered behavior.
Part of brief therapy means meeting the client where they are at, and developing mutually agreeable goals.
Topics to cover in Eating Disorder Treatment include
What Is An Eating Disorder
How Ready Am I To Change
How Eating Disorders Are Maintained
Regular Eating and Weighing
Binge, Purge, Driven Exercise
Moods: Distress Tolerance and Coping Skills
Over-evaluation of Weight and Shape
Challenging Thoughts and Dietary Rules
Checking, Avoidance and Feeling Fat
Improving Low Self-esteem
What Are Mindsets
~ Changing Mindsets
~ Relapse Prevention
~ Develop mutually agreeable goals focusing on what the client hopes to achieve
~ Use the miracle question to help clients identify their goals
~ Support the client’s successes and avoid reinforcing undesired behaviors
~ Explore the use of journals and the handouts to help clients process between sessions
~ Develop a relapse prevention plan early in treatment to help clients address the main presenting symptom.