Old Female Concerned About Possible Eating Disorder

Reason for Referral

A 35 year old female was referred to counselling by her family doctor, Dr White, after a phone call from the client's mother, who was concerned about that her daughter may have an eating disorder. The mother also spoke to her daughter about her concerns and encouraged her to seek counselling. The client does not believe that, she has an eating disorder but has presented to counselling to please her mother.

Presenting Problem

The client's presenting condition is a non-otherwise specified eating disorder, with feelings of loneliness and isolation sustained by her beliefs of self-worth surrounding her weight that has resulted in past self-criticism. Lack of social connection is compensated by binge eating as a reward system to self-soothe. The underlying problem is the lack of emotional bonding, connection, interacting and sharing, which is similar to her childhood. Although the client can connect in her working environment, she is unable to socialise in her personal life, which perpetuates her loneliness.

Relevant Background Information

The client is pleasant, well mannered and polite, who has presented to counselling on the request of her mother. Despite the client not believing, she has any presenting issues, she has come to the

session to please her mother and "get her off her back". The client is an only child and her parents are still alive and married. She has no siblings, and she did not have any pets growing up, as this would have messed the house up. Her mother kept a very tidy home and would get upset and anxious if things were not in order. Client states that, her upbringing was very calm and did not suffer from any physical or sexual abuse. However, the only thing that made her upset was when her mother experienced anxiety, when there was disorder. There was no physical expression of affection growing up but believes her mother expressed her love by doing "mother functions", such as keeping the house tidy. Parents did not express physical affection, and there was no touching growing up. There was interaction with her family members, but no huge display of emotions other than her mother's anxiety. The client described her upbringing as lonely and lacking fun. The client spent most of her childhood reading and drawing and performed good grades in school. The client did not have many friends in high school and did not know how to connect or fit in. During her junior summer the client lost a considerable amount of weight and on her return to school things changed. She began to get attention from boys and was noticed for the first time.

In her senior year she dated often, which also involved binge drinking, but experienced some bullying and people says mean things about her. This hurt her feelings and because of that, in her sophomore year she began to isolate, which also involved drinking on her own. Through the drinking, she began to gain some of the weight back, which in turn meant that the boys were no longer interested. The client believes that, not having the attention from the boys was better, as she was able to maintain some of her female friendships, but that she felt isolated. The client has completed college and works as a travel agent. Although she enjoys her work, she does not socialise much and if not working she spends most of her time at home on her own. The client states that, her mother believes that, if she lost some weight, she could go out and socialise more and would like her to get married. The client spends most weekends at home on her own, which she enjoys. The client’s eating patterns are to binge eat junk food on the weekends, doughnuts, which is somewhat of a treat, and then eat less during the week to balance it out. The client has not dated very much after college but reports that, she was engaged for one and a half years and that he left the relationship two years ago due to her self-criticism.

In her senior year she dated often, which also involved binge drinking, but experienced some bullying and people says mean things about her. This hurt her feelings and because of that, in her sophomore year she began to isolate, which also involved drinking on her own. Through the drinking, she began to gain some of the weight back, which in turn meant that the boys were no longer interested. The client believes that, not having the attention from the boys was better, as she was able to maintain some of her female friendships, but that she felt isolated. The client has completed college and works as a travel agent. Although she enjoys her work, she does not socialise much and if not working she spends most of her time at home on her own. The client states that, her mother believes that, if she lost some weight, she could go out and socialise more and would like her to get married. The client spends most weekends at home on her own, which she enjoys. The client’s eating patterns are to binge eat junk food on the weekends, doughnuts, which is somewhat of a treat, and then eat less during the week to balance it out. The client has not dated very much after college but reports that, she was engaged for one and a half years and that he left the relationship two years ago due to her self-criticism.

Treatment History

The client attended her General Practitioner Doctor White, on the request of her mother. From Dr White's consultation, it was concluded that, there were some signs of an eating disorder and was referred on for counselling. The client has not sought counselling in the past regarding her eating patterns. The client has had no previous counselling or any form of therapeutic intervention.

Summary

A 35-year-old woman was referred to counselling by her GP at the request of her mother for a suspected eating disorder. The client experiences feelings of loneliness and isolation sustained by her beliefs of self-worth that has resulted in past self-criticism. There is a lack of social connection, which is compensated by binge eating as a reward system to self-soothe. The underlying problem is the lack of emotional bonding, connection, interacting and sharing, which is similar to her childhood. Although the client can connect in her working environment, she is unable to socialise in her personal life, which further perpetuates her loneliness.

Predisposing factors

Predisposing factors, which could help explain the clients presenting issues include her childhood history of loneliness and lack of physical connection to her primary caregivers. This lack of affection reflected onto her social life as a child with no real connections and not having a strong social support network of friends. The result of her mother's anxiety towards tidiness led to a lonely childhood, which was reflected in her disconnection to peers, 'unable to have friends over to her house because they would mess the house up'. Additionally, the lack of physical connection and expression of emotions by her parents are likely to have created feelings of unworthiness of love and self-criticism. These experiences as a child were likely to have had an influence on her experiences at college of not fitting in. Another predisposing factor could also be having witnessed her mother's anxiety, which led the client feeling upset and wanting to keep things calm in the home as it took her mother some time to settle down, suggesting her mother's anxiety could be the reason behind how the client learnt to isolate and cope with stressful situations.

Precipitant factors

The precipitating factors to the client's presenting issue are the relationship with her mother, as it was her mother that instigated the need for counselling and her concern around the client's eating patterns. The pressure from her mother to lose weight and the lack of socialising may be feeding her self-criticism and sense of not worthy of being loved. Her isolation coping style and self-soothing binge eating are currently exacerbating her loneliness, which in turn creates disconnection and low self-esteem. A past relationship breakup has potentially left her feeling unworthy of love and more isolated. Furthermore, she may be experiencing shame by her binge eating, which could have been precipitated by her mother speaking to her GP.

Perpetuating factors

The core-perpetuating factor for why this problem continues to persist is the client's feelings of loneliness and disconnection, which has resulted in her pattern of self-soothing on the weekends with binge eating. Several unresolved predisposing factors are contributing to why the problem persists.

The pattern of isolation is predisposed by the absence of love and affection growing up. This isolation has been a continued avoidance pattern that she turned to as a child to remove herself from her mother's anxiety and that she often returns. Furthermore, she uses the binge eating to self-soothe making up or avoidance of what is missing from her life.

The client's eating disorder has persisted due to several unresolved issues including, how she thinks others perceive her, how she views herself, not having CBT strategies to help her address or combat her loneliness, negative self-talk, and lack of a strong friendship.

Ongoing low self-esteem has also been a perpetuating factor, which entails a potential core belief that, she is only worth loving if she is slim (her mother's belief) resulting from a parenting style lacking in warmth and affection.

Underlying trauma from negative self-talk and self-blaming may have exacerbated her feelings of loneliness, and a pattern of avoidance of emotion has led to disconnection and the cycle of an eating disorder to self-soothe her loneliness.

Protective factors

There is evidence to suggest that the client has several protective factors, including a healthy work-life and overall, she is in good physical health.

The client does not suffer anorexia nervosa or bulimia, which suggests that she is aware of the need to have a somewhat balanced diet. Furthermore, the client's relationship, even though lacking in affection, with her mother, maybe one of the few if not only, constant relationships she has. These are very encouraging resources, strengths and opportunities to have, which can help to provide support for assisting her in overcoming her current non-otherwise specific eating disorder due to loneliness.

Primary global

In order to resolve the clients presenting symptoms of binge eating that is a consequence of her loneliness driven by her underlying feeling of self-worth, not worthy of being loved and self-criticism. The goal is to bring awareness to her maladaptive schema and build herself worth and confidence providing the ability to develop a more realistic assessment of her thoughts, feelings and behaviours (using the ACB model). The second goal will be to build relationships and begin socialising to negate loneliness that results in binge eating.

Cognitive Behavioural Therapy (CBT) has been selected as the most appropriate therapy.

Rationale for using CBT

Due to the client's challenges with engaging in social activities, which lead to her pattern of isolation, binge eating, driven by her underlying feeling of self-worth, which is a result from her upbringing and her relationship with her mother, that brings about negative self-talk and criticism, a Cognitive Behaviour Therapy (CBT) approach, seems to be the most obvious choice of treatment for primarily addressing her patterns of self-criticism and sense of unworthiness. Secondarily, treating her non-otherwise specified eating disorder is the consequence of her core beliefs.

The leading evidence-based treatment for eating disorders is Cognitive Behavioural Therapy (CBT). CBT is a psychotherapeutic approach requiring a wide variety of methods. Such strategies help a person to understand the relationship between his or her thoughts or perceptions, emotions and behaviours and establish techniques for modifying unhelpful thoughts and behaviours to enhance mood.

CBT fundamental concepts are that our feelings are strongly linked to our thoughts and our behaviours. The ideas or schemas of a client underlie the way from day to day she/he understands and navigates interactions. Generally speaking, these schemas are not apparent and mostly automatic.

Automatic thinking requires a clear consciousness to untangle ill-adapted thinking from positive and productive thinking. A client's schemes are described, measured and examined using CBT

It is now popular opinion in the literature that while food, weight and shape abnormalities are crucial to explain food disorders, it is more relevant and suggested that, cognitive behavioural models of eating disorders concentrate on the role of 'deeper' schema-level concepts unrelated to food, weight, and shape in the eating disorder. (Innovations and Advances in Cognitive Behavioural Therapy)

First session

Providing individual CBT therapy to address dysfunctional thinking and behaviours. Explaining that the program is based on 12 weekly sessions. Treatment can include sharing difficult experiences and feeling, but the client can monitor the depth of such conversations. Therapy will be most effective if the client attends sessions regularly (weekly sessions).

Providing the client feedback on the case formulation and agree on the treatment goals. Providing the reason for using CBT treatment and how CBT works (challenges thoughts and habits which are often unconscious, pessimistic and not necessarily the most effective way of seeing things). Explaining that within the CBT model we will explore awareness of her perceptions, feeling and actions and discuss that modifying one's thinking style (thoughts) can alter her emotions and actions. Looking at specific approaches for self-criticism reduction and present ideas about how rational her perceptions are.

Setting out homework tasks and explaining the meaning and importance of homework within the CBT model. The client will be encouraged to be open with the therapist about any parts of therapy; they are not finding helpful or feel uncomfortable.

Experimentation and Practice

7-8 Weekly sessions of CBT (50 minutes in duration)

Providing time for the week's review, homework analysis and setting the schedule for this week's session. Every session will finish with setting homework and suggestions on how the client felt the session was going.

Session outlook list:

1. Check the client's mood/feelings (HAM-A)

2. A brief review of the week.

3. Set agenda for the current session.

4. Feedback and link to, previous session

5. Review homework.

6. Discuss agenda items (cognitive strategies)

7. Set homework (Thought record to track negative self-talk).

8. Seek feedback at the end of the session

Exploring how the client's thoughts and behaviours influence the "causes" and symptoms of binge eating and how these might be improved. Help the client to understand the interaction between her thoughts, feelings, and behaviours and develop strategies to change unhelpful thoughts and behaviours to improve mood and functioning. (Mood diary)

Establishing a baseline of feelings and consequences, i.e. how often do you have negative thoughts about yourself? How often do you feel lonely? What do you do when you feel alone?

Ask questions about current thoughts and feelings. Client may respond, "It is better to be on my own than to have people in my life judge me or say bad things about me" or "I'm not attractive enough for anyone to love me" or "He will leave me anyway if I am not slim enough."

Challenging her thoughts above to expand her thinking. For example, "It is better to be on my own than to have people in my life judge me or say bad things about me Ask her to provide evidence for these thoughts to prove her thoughts are correct, ask her if these thoughts make her feel better? (Has she got specific examples to prove this?). Ask her what her strengths are; explore the strengths that she recognises? Ask if there are alternative ways of viewing her thoughts. For example – "I am loveable whatever my weight is". Educate that current automatic thoughts like this can be contaminated with past experiences that are not true or are maladaptive. (The client's view of her past experiences of not having affection, or her loneliness growing up with her emotions of unhappiness, or thoughts of self-criticism, and contaminating feelings of being not worthy of love).

Explaining and implement the use of "Thought Record" and commence using this in session to record thoughts and the emotions she is feeling with them. Grade these with regard to how much she believes them to be accurate and grade the intensity of the associated emotion. Write down evidence that doesn't support the thought and give an alternative view.

Homework setting – Use of Thought Record between sessions and bring to each session to discuss. Implement the use of mood diary to record and consider the consequences of her moods, mapping what feelings result in binge eating.

2-3 weekly sessions to end therapy

The first is being able to regulate one's feelings for understanding and tracking the feelings. By monitoring their feelings, clients can begin to learn how they react to various situations and events, the kind of thoughts that could lead to their belief, how they could develop greater control of their emotions and how they can boost the overall mood. Mood monitoring aims to help the client to identify and label emotions and rate their intensity over time.

Stepping three and moving towards the termination of treatment, the emphasis shifts to the future. The goal shifts to building relationships and beginning socialising to negate feelings of loneliness that results in binge eating. The awareness and change in her maladaptive schema can now provide focus on creating the life she wants. Implement Graded Exposure by defining situations that lead to isolation, discriminate between them, grade them and put in an ordered list to educate. Introduce the use of imaginable exposure by vividly imagining a socialising situation or activity. For example, ask to recall her time in college when she went out to parties and had friendships, describing her experience to reduce the feelings of fear.

Homework setup of Self-efficacy, for the client to try one socialising experience, however short, that can help to show the client that she is capable of having friends and can manage the feelings of unworthiness and self-criticism.

Once the client is comfortable and fully engaged in one social activity, discuss with the client her progression and try and get her to participate in more than one social event.

It is essential to also focus on dealing with setbacks and maintaining the changes that have been obtained. Normalising with the client that a setback is a time when you go "backwards" a little in your progress because specific negative thoughts popped into your head at an inopportune time when you weren't expecting it.

Finally, discuss with the client their overall progression and their newly established thoughts, feelings and beliefs about themselves, reinforce that they should be proud of themselves and consider ending the therapist's involvement with the client. However, reassure the client that they are more than welcome to come back if any of their behaviour of binge eating resurfaces or any other mental health issues arise.

A review session is generally some months after the end of the treatment. It offers a chance to assess progress and address any existing or developing issues.

Treatment Outcomes

One of the expected treatment outcomes for the client after addressing dysfunctional thinking and behaviours that leads to loneliness and binge eating by exploring how the client's thoughts and behaviours influence the "causes" and symptoms of binge eating will be to regulate her feelings by understanding and tracking them. By monitoring her feelings, she can begin to learn how she reacts to various situations and events, the kind of thoughts that could lead to her feelings, how to develop greater control of her emotions and how to boost her overall mood. With the use of the Mood diary and a thought diary, the client will be able to see her patterns of maladaptive schema and undertaking extensive gradual exposure therapy will provide focus on creating the life she wants. By implementing Graded Exposure by defining situations that lead to isolation, discriminate between them, grade them and put in an ordered list to educate, the client will begin to become more comfortable with socialising which will negate her feeling of isolation and loneliness that results in binge eating.

The treatment will be monitored regularly over the client's counselling sessions by frequent verbal reviews with the therapist at the end of each session and by direct analysis and examination at the beginning of each session about how she progressed through her homework tasks and activities.

Using my clinical experience to track improvement in her behavioural signs (i.e. binge eating) and cognitive abilities to self-identify negative emotions and ill-adaptive behaviour patterns and interrupt them with techniques learned (i.e. self-efficacy) will also help in the assessment of therapy.

Since the client presented to clinic on the insistence of her mother and doctor, it will be essential to monitor the client's attendance and commitment to sessions and observe her strengths, praise any shifts, and encourage steps made towards change. Reassuring the client that, she is more than welcome to come back if any of her behaviours of binge eating resurfaces or any other mental health issues arise

References

Danielle Einstein, Australian Academic Press, (2007). Innovations and Advances in Cognitive Behaviour Therapy. ProQuestEbook Central,

Hannah Turner, Madeleine Tatham, Victoria A. Mountford, Tracey D. Wade, and Glenn Walle, (2019). Brief Cognitive Behavioural Therapy for Non-Underweight Patients : CBT-T for Eating Disorders. London: Taylor & Francis Group.

Orygen, (2015). Cognitive–behavioural therapy for depression in young people A modular treatment manual. The National Centre of Excellence in Youth Mental Health

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