Adult Treatment Planner

Objectives and Interventions

• Honestly describe the pattern of eating including types, amounts, and frequency of food consumed or hoarded.
  • Establish rapport with the client toward building a therapeutic alliance.
  • Assess the amount, type, and pattern of the client's food intake (e.g., too little food, too much food, binge eating, or hoarding food).
  • Compare the client's calorie consumption with an average adult rate of 1,500 calories per day to determine over- or undereating.
• Describe any regular use of dysfunctional weight control behaviors.
  • Assess for the presence of self-induced vomiting behavior by the client to purge himself/herself of calorie intake; monitor on an ongoing basis.
  • Assess for the client's misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise; monitor on an ongoing basis.
• Complete psychological tests designed to assess and track eating patterns and unhealthy weight-loss practices.
  • Administer a measure of eating disorders to further assess its depth and breadth (e.g., self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise) and/or to track treatment progress (e.g., The Eating Disorders Inventory-2 by Garner, 1991).
• Cooperate with a complete physical exam.
  • Refer the client to a physician for a physical exam and stay in close consultation with the physician as to the client's medical condition and nutritional habits.
• Cooperate with a dental exam.
  • Refer the client to a dentist for a dental exam.
• Cooperate with an evaluation by a physician for psychotropic medication.
  • Assess the client's need for psychotropic medications (e.g., SSRIs); arrange for a physician to evaluate for and then prescribe psychotropic medications, if indicated.
• Take medications as prescribed and report effectiveness and side effects.
  • Monitor the client's psychotropic medication prescription compliance, effectiveness, and side effects.
• Cooperate with admission to inpatient treatment if indicated.
  • Refer the client for hospitalization, as necessary, if his/her weight loss becomes severe and physical health is jeopardized, if he/she is severely depressed or suicidal.
• Verbalize an accurate understanding of how eating disorders develop.
  • Discuss with the client a model of eating disorders development that includes concepts such as sociocultural pressures to be thin, vulnerability in some individuals to overvalue body shape and size in determining self-image, maladaptive eating habits (e.g., fasting, binging), maladaptive compensatory weight management behaviors (e.g., purging), and resultant feelings of low self-esteem (see Overcoming Binge Eating by Fairburn).
• Verbalize an understanding of the goals of and rationale for treatment.
  • Discuss a rationale for treatment that includes using cognitive and behavioral procedures to break the cycle of thinking and behaving that promotes poor self-image, uncontrolled eating, and unhealthy compensatory actions while building physical and mental health-promoting eating practices.
  • Assign the client to read psychoeducational chapters of books or treatment manuals on the development and treatment of eating disorders (e.g., Overcoming Binge Eating by Fairburn).
• Keep a journal of food consumption.
  • Assign the client to self-monitor and record food intake, thoughts, and feelings (or assign "A Reality Journal: Food, Weight, Thoughts, and Feelings" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma, or "Daily Record of Dysfunctional Thoughts" in Cognitive Therapy of Depression by Beck, Rush, Shaw, and Emery); process the journal material to challenge maladaptive patterns of thinking and behaving, and replace them with adaptive alternatives.
• Establish regular eating patterns by eating at regular intervals and consuming at least the minimum daily calories necessary to progressively gain weight.
  • Establish a minimum daily caloric intake for the client and assist him/her in meal planning.
  • Establish healthy weight goals for the client per the Body Mass Index (BMI = pounds of body weight × 700/height in inches/height in inches; normal range is 19 to 24 and below 17 is medically critical), the Metropolitan Height and Weight Tables, or some other recognized standard.
  • Monitor the client's weight and give realistic feedback regarding body thinness.
• Attain and maintain balanced fluids and electrolytes as well as resumption of reproductive functions.
  • Monitor the client's fluid intake and electrolyte balance; give realistic feedback regarding progress toward the goal of balance.
  • Refer the client back to the physician at regular intervals if fluids and electrolytes need monitoring due to poor nutritional habits.
• Identify and develop a hierarchy of high-risk situations for unhealthy eating or weight loss practices.
  • Assess the nature of any external cues (e.g., persons, objects, and situations) and internal cues (thoughts, images, and impulses) that precipitate the client's uncontrolled eating and/or compensatory weight management behaviors.
  • Direct and assist the client in construction of a hierarchy of high-risk internal and external triggers for uncontrolled eating and/or compensatory weight management behaviors.
• Identify, challenge, and replace self-talk and beliefs that promote the eating disorder.
  • Assign the client to self-monitor and record food intake, thoughts, and feelings (or assign "A Reality Journal: Food, Weight, Thoughts, and Feelings" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma, or "Daily Record of Dysfunctional Thoughts" in Cognitive Therapy of Depression by Beck, Rush, Shaw, and Emery); process the journal material to challenge maladaptive patterns of thinking and behaving, and replace them with adaptive alternatives.
  • Assist the client in developing an awareness of his/her automatic thoughts and underlying assumptions, associated feelings, and actions that lead to maladaptive eating and weight control practices (e.g., poor self-image, distorted body image, perfectionism, fears of failure and/or rejection, fear of sexuality).
  • Do "behavioral experiments" in which the client's identified automatic thoughts are treated as hypotheses/predictions, more adaptive, reality-based alternative hypotheses/predictions are generated, and both are tested through homework exercises.
• Participate in exposure exercises to build skills in managing urges to use maladaptive weight control practices.
  • Conduct imaginal exposure and ritual prevention to the client's high-risk situations (e.g., purging, excessive exercising); select initial exposures that have a high likelihood of being a successful experience for the client; prepare and rehearse a plan for the session; do cognitive restructuring within and after the exposure; review/process the session with the client (e.g., exposure to eating high-carbohydrate foods while resisting the urge to self-induce vomiting).
• Complete homework assignments involving behavioral experiments and/or exposure exercises.
  • Assign the client a homework exercise in which he/she repeats the in-session behavioral experiment or exposure exercise between sessions and records responses; review the homework, doing cognitive restructuring, reinforcing success, and providing corrective feedback toward improvement.
• Discuss important people in your life, past and present, and describe the quality, good and bad, of those relationships.
  • Conduct Interpersonal Therapy, assessing the client's "interpersonal inventory" of important past and present relationships and evidence of themes that may be supporting the eating disorder (e.g., interpersonal disputes, role transitions, and/or interpersonal deficits).
• Learn and implement problem-solving and/or conflict resolution skills to resolve interpersonal problems.
  • Teach the client conflict resolution skills (e.g., empathy, active listening, "I messages," respectful communication, assertiveness without aggression, compromise); use modeling, role-playing, and behavior rehearsal to work through several current conflicts.
  • Help the client resolve interpersonal problems through the use of reassurance and support, clarification of cognitive and affective triggers that ignite conflicts, and active problem-solving.
  • In conjoint sessions, help the client resolve interpersonal conflicts.
• Implement relapse prevention strategies for managing possible future anxiety symptoms.
  • Discuss with the client the distinction between a lapse and relapse, associating a lapse with an initial and reversible return of distress, urges, or to avoid and relapse with the decision to return to the cycle of maladaptive thoughts and actions (e.g., feeling anxious, binging, then purging).
  • Identify and rehearse with the client the management of future situations or circumstances in which lapses could occur.
  • Instruct the client to routinely use strategies learned in therapy (e.g., continued exposure to previous external or internal cues that arise) to prevent relapse.
  • Schedule periodic "maintenance" sessions to help the client maintain therapeutic gains and adjust to life without the eating disorder.
• State a basis for positive identity that is not based on weight and appearance but on character, traits, relationships, and intrinsic value.
  • Assist the client in identifying a basis for self-worth apart from body image by reviewing his/her talents, successes, positive traits, importance to others, and intrinsic spiritual value.
• Attend an eating disorder group.
  • Refer the client to a support group for eating disorders.