By Samantha Dashineau, M.A., Purdue University
Many clinical psychology programs do not explicitly train graduate student clinicians to work with certain populations, such as those diagnosed with eating disorders. As a result, trainees in these programs are often tasked with finding practicum placements to receive experience treating these populations. There are a variety of considerations that early career therapists must take when beginning to work with clients with eating disorders that (in my experience) are not taught at a student’s home institution. This primer is not exhaustive, but rather covers what I would suggest as the most important pieces of information to consider.
Intake Considerations
- First, perhaps more frequently relative to other disorders, therapists are tasked with determining appropriateness for outpatient treatment at intake, given the research finding eating disorders’ well-established links to deleterious health outcomes (e.g., Ramocciotti et al., 2003). Given that many outpatient facilities are not equipped to address medical or metabolic issues clients may present with, thoughtfulness must be taken to ensure that clients medical as well as psychological needs can be addressed at an appropriate level of care.
- Intake for a client should include specific assessment of eating behaviors (including details about daily caloric intake), compensatory strategies (how frequent/intense exercise), food rituals (specific manners of eating or rules about food) and body checking (measuring body parts, weighing, examining in the mirror). A thorough assessment must establish the frequency, duration, and intensity of this behavior and should include collaboration with a dietician and medical professional (i.e. Yager et al., 2005).
- For many clients, these questions can be overwhelming, as clients with eating disorders present with shame regarding eating behaviors as well as body image (Nechita et al., 2021). A gentle, non-judgmental approach which favors close ended questions may be necessary to determine severity if clients are particularly reserved.
Treatment Readiness
- Many clients (in my anecdotal experience) report reluctance to give up the “safety” that an eating disorder can provide. While clients describe distress and an intention to gain freedom from disordered eating, many also describe their eating disorder as offering a means of control and express ambivalence as to whether they can envision a life without it. In addition, presence of eating disorder symptoms and past traumatic experiences are highly related and providers must be careful to assess for past trauma in order to most wholly treat the client (Trottier & MacDonald, 2017).
- For others, eating behaviors may be in response to deeply ingrained messaging about their body (e.g., Derenne & Beresin, 2006). It is important for the therapist to consider the function of the eating behaviors (i.e., drive for thinness, emotion regulation, etc.) to understand the best path forward in treatment. This is an understudied area of eating disorders, with more data needed to best understand the prognostic significance of maintenance factors (Stice, 2002).
Initial Treatment
- Initial treatment targets should include addressing ambivalence and assessing the overall impact disordered eating is having on the client. Motivational interviewing or informal exploration of reasons for treatment may be important to explore.
- Care should be taken when using examples from manualized treatment, as many involve mentions of food or exercise that may be counterproductive to the intervention. For example, in the DBT Skills manual, for the distress tolerance skill of TIPP, therapists should skip the “T”, which is temperature change as it is not indicated for patients with eating disorders as well as the “I”, which is intense exercise (Linehan, 2014). The manual points this out, but care must be taken ahead of time to adapt interventions to this population.
- Likewise, in many short-term therapeutic strategies like behavioral activation, care must be taken to use relevant examples to the context, omitting exercise plans particularly in the early stage of treatment.
In sum, overall thoroughness in assessment, comfort working with ambivalence and flexibility in adapting treatment is important for treating disordered eating.
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References
Derenne, J. L., & Beresin, E. V. (2006). Body image, media, and eating disorders. Academic psychiatry, 30, 257-261.
Linehan, M. (2014). DBT Skills training manual. Guilford Publications.
Nechita, D. M., Bud, S., & David, D. (2021). Shame and eating disorders symptoms: A meta‐analysis. International Journal of Eating Disorders, 54(11), 1899-1945.
Ramacciotti CE, Coli E, Biadi O, Dell’Osso L: Silent pericardial effusion in a sample of anorexic patients. Eat Weight Disord 2003; 8:68–71
Stice, E. (2002). Risk and maintenance factors for eating pathology: a meta-analytic review. Psychological bulletin, 128(5), 825.
Trottier, K., & MacDonald, D. E. (2017). Update on psychological trauma, other severe adverse experiences and eating disorders: state of the research and future research directions. Current psychiatry reports, 19(8), 1-9.
Yager, J., Devlin, M. J., Halmi, K. A., Herzog, D. B., Mitchell, J. E., Powers, P. S., & Zerbe, K. J. (2005). Guideline watch: Practice guideline for the treatment of patients with eating disorders. Focus, 3(4), 546-551.
Disclaimer: The views and opinions expressed in this newsletter are those of the authors alone and do not necessarily reflect the official policy or position of the Psychological Clinical Science Accreditation System (PCSAS).