The book is divided into four sections: Section 1: Foundations; Section 2: Assessment and Practice Frameworks for Eating Disorders and Obesity; Section 3: Effective Prevention and Early Intervention for Eating Disorders and Obesity; and Section 4: Effective Treatments for Eating Disorders and Obesity.
Section 1: Foundations
Section 1 provides information for understanding the sociocultural context in which EDs and obesity occur. Counselors need a firm understanding of cultural influences and risk factors to assist in the assessment, prevention, and treatment planning for these problems, including how interventions must account for environmental influences (e.g., media, family, peers) as well as for differences in gender and race and ethnicity. Ethical and legal considerations to increase counselor competence in this area are also explored.
First, Linda Smolak and Caitlin Chun-Kennedy address the role of sociocultural influences in the development of body image disturbance and disordered eating symptoms, two of the strongest risk factors for EDs and obesity. They discuss the influences of media, peers, and parents as three primary sociocultural agents operating to shape body image development and describe individual differences regarding individuals who are most vulnerable to these influences.
In Chapter 2, Margo Maine and Douglas Bunnell coauthor a chapter on gender and its impact on the prevention and treatment of both women and men with EDs. Because gender is a leading risk factor for the development of EDs, understanding how current gender role development affects an individual's risk and how gender-based factors can maintain and reinforce eating problems is important. Maine and Bunnell also address gender differences in the expression of EDs and provide counseling strategies for providing gender-sensitive treatment to both men and women who experience disordered eating.
Chapter 3 examines the importance of cultural influences through Regine M. Talleyrand's discussion of EDs and obesity in people of color. As discussed previously, eating- and weight-related problems are more common among people of color than previously thought, and counselors have an ethical responsibility to detect and assess for these problems in their clients. In her chapter, Talleyrand reviews existing research conducted with specific cultural groups and discusses cultural factors that might put a client at risk for the development of ED symptoms and obesity. She also provides counseling strategies to help counselors deliver more culturally sensitive assessment, prevention, and treatment for clients of color.
A final foundational chapter in Section 1 highlights important ethical and legal concerns when working with clients with EDs. Although clients with other mental health symptoms generally want to be rid of their problems, clients with EDs are frequently opposed to seeking treatment or altering disordered eating behaviors. In Chapter 4,1, Mary A. Hermann, and Leigh Pottle explore the ethical and legal complexities involved for counselors who work with clients who do not want to change life-threatening behaviors. Counselors must carefully balance the need to respect clients' ability to make their own life decisions while also fulfilling their own duty to protect clients from self-inflicted harm. The chapter also reviews counselors' ethical duty to increase their self-awareness and to practice within their own scope of competence. The authors also review the issue of client autonomy in detail, describing issues related to informed consent and treatment decision making. The use of an ethical decision-making model is also demonstrated through a case example authored by Jodi Manton, a master's degree candidate at Louisiana State University.
Section 2: Assessment and Practice Frameworks for Eating Disorders and Obesity
Assessment of client concerns is critical in identifying problems, conceptualizing client concerns, and conducting effective prevention and treatment planning. This section includes criteria from the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev., or DSM-IV-TR; American Psychiatric Association [APA], 2000) as well as the most recent proposed guidelines for the fifth edition of the DSM (DSM-5; American Psychiatric Association, 2012) to guide the discussion of assessment. Next, it includes chapters on two frameworks for guiding intervention decisions so that counselors can be more informed about determining where a client might need to enter the continuum of care, which ranges from prevention to intensive treatment.
In Chapter 5, Kelly C. Berg and Carol B. Peterson provide a careful overview of both the DSM-IV-TR and the DSM-5 diagnostic criteria for the ED spectrum. Because eating- and weight-related concerns are so common, Berg and Peterson recommend that assessment for EDs be integrated into all initial intake interviews, and they provide detailed descriptions for incorporating screening questions into a clinical interview. They also address special considerations for assessment and diagnosis of EDs, including working with children (who might not be developmentally capable of understanding typical screening questions) and with clients of color.
Many eating- and weight-related problems emerge during the later childhood and adolescent years, indicating that youths experiencing these concerns spend most of their waking hours attending school. It makes sense, then, that school counselors can play an important role in detecting the early onset of eating issues and in serving as a resource to ensure that student needs are met. In Chapter 6, Jennifer Maskell Carney and Heather Lewy Scott provide information for school counselors on identifying, assessing, and intervening with students who have eating- and weight-related concerns. Specifically, they provide school counselors with a framework guided by the American School Counselor Associations National Model for conceptualizing and providing interventions for client concerns across the continuum of care, ranging from body image concerns, disordered eating (including binge eating, which leads to obesity), and EDs.
Although Carney and Scott's chapter focuses specifically on school- based intervention and referrals, in Chapter 7, Alan M. Schwitzer presents a framework for assessing and planning community-based interventions for young women with eating disorder not otherwise specified. Because this disorder is by far the most common ED, Schwitzer provides a model for working with clients who have it, including assessment guidelines, case conceptualization strategies, and a menu of counseling responses for prevention, early intervention, and treatment. Schwitzer's chapter is unique in that it is supplemented by journal entries and writings of contributor Constance Rhodes (author of Life Inside the “Thin” Cage; 2003), who writes vividly about her personal experience and recovery from ED not otherwise specified.
Section 3: Effective Prevention and Early Intervention for Eating Disorders and Obesity
Because EDs and obesity are preventable public health concerns, this section of the book includes important chapters on prevention. Prevention is highly preferable to remediation and treatment in that prevention efforts can be successfully implemented in the childhood and adolescent period before serious problems occur. Prevention and early intervention are foundational to the practice of professional counseling, and counselors are well suited to provide prevention programs for schools and communities. This section includes two chapters on the prevention of EDs and obesity in children, two chapters on prevention in young adults and college students, and a final chapter regarding a culturally adapted guided self-help program that has demonstrated effectiveness with a community-based group of Mexican American women.
Janet A. Lydecker, Elizabeth Cotter, Rachel W. Gow, Nichole R. Kelly, and Suzanne E. Mazzeo's focus in Chapter 8 is on the prevention of obesity in children and adolescents. They provide evidence that the prevention of pediatric overweight and obesity should be a public health priority because of its potential short- and long-term medical and psychological consequences. In their chapter, the authors describe primary prevention interventions that can be implemented for all youths, including school- based interventions (changing school meals, vending machines, physical education), government policies (e.g., changing restrictions on media, food industry, pricing), and community-based interventions (e.g., food access and physical activity in local neighborhoods, addressing barriers related to culture and food or physical activity). They also examine secondary obesity prevention programs that target youths who are at risk of becoming overweight or obese. In particular, they describe the counselor's role as a behavioral specialist, using motivational interviewing strategies and family-based interventions in providing support for realistic goal setting in the areas of nutrition and physical activity.
In Chapter 9, Niva Piran discusses the importance of a counselor's role in preventing EDs in children. Because an increase in disordered eating symptoms and ED problems is occurring at younger ages, Piran asserts that preventing these problems from developing in children is far preferable to the complex treatment that is required when eating-related problems become entrenched in adolescence and early adulthood. Rather than focusing on the symptom level, Piran emphasizes the necessity of prevention programs that target the multiple systems in childrens lives, including broader social forces that operate in the school and community environment. Piran details her emerging developmental theory of embodiment, which explicates the array of social experiences that shape the development of body image. After detailing this model, she then presents strategies for early intervention and prevention programs that are framed by an ecological developmental perspective.
In Chapter 10, Heather Shaw and Eric Stice address the prevention of EDs in older adolescents and young adults. After providing a thorough overview of ED prevention research, the authors highlight examples of effective universal, selective, and indicated prevention programs. Next they provide a detailed description of the Body Project, an empirically supported dissonance-based secondary prevention program in which young women at risk for EDs because of body image concerns spend four sessions critiquing the thin ideal for women through verbal, written, and behavioral exercises (Stice, Mazotti, Weibel, & Agras, 2000). The Body Project groups are highly applied and interactive, requiring participants to learn new skills through insession exercises, homework, and increased commitment to change through participation in motivational enhancement exercises.
Deanne Zotter and Justine Reel (Chapter 11) turn readers' attention to the prevention of eating- and weight-related concerns in college and university settings. They provide a review of disordered eating behaviors and body image concerns in college and university populations, including those that occur in subpopulations most at risk for these problems: sorority women, college athletes, and students majoring in health and physical education. The authors describe research-supported prevention efforts designed specifically for university settings including Internet-based programs and tailored prevention programs for specific at-risk college-based groups.
Finalizing the section on prevention is a chapter on an indicated prevention program for individuals who have early-onset eating- or weight-related problems. In Chapter 12, Fary M. Cachelin, Munyi Shea, and Frances A.
Bono present a culturally sensitive indicated prevention program (cognitive-behavioral therapy guided self-help) for clients with early-onset bulimia nervosa and binge eating disorder. Cachelin and colleagues review the structure, contents, and counselors role in these programs and describe how they adapted the program specifically for a group of Mexican American women. This type of early intervention is ideal for clients from diverse cultural groups who may have developed initial symptoms but might not be ready or willing to attend individual counseling.
Section 4: Effective Treatments for Eating Disorders and Obesity
For clients who are in need of more intensive approaches than the prevention and early intervention programs described in the previous sections, Section 4 addresses the current evidence-based and recommended psychosocial outpatient treatments for EDs and obesity (APA, 2006; Wilfley et al., 2007), which are also those that are most likely to fall within counselors' scope of practice. EDs and obesity generally necessitate a multidisciplinary approach to treatment, including counseling, medical monitoring, medication, or even hospitalization. For children and adolescents, family involvement is also deemed essential (APA, 2006; Epstein, Wing, Koeske, & Valoski, 1987).
Despite these commonalities, and although many of the treatment approaches described in this section have theoretical concepts and treatment components that overlap, several distinct approaches to effective treatment exist; some require detailed attention to changing disordered eating patterns through monitoring and behavioral change projects (e.g., enhanced cognitive-behavioral therapy [CBT-E]), and others do not attend to the eating patterns at all but focus on the interpersonal problems that purportedly drive the behavior (e.g., interpersonal therapy, relational cultural therapy). It is therefore important for counselors to review the treatment approaches described here carefully, note the research findings regarding what works best for which particular subpopulation of clients, and implement the treatment only after obtaining additional reading and appropriate supervised practice.
In Chapter 13, Anthea Fursland and Hunna J. Watson focus on CBT-E (Fairburn, 2008), a treatment appropriate for all EDs because of its transdiagnostic nature. It has received strong research support in clinical and community trials, and the original cognitive-behavioral therapy (CBT) for bulimia nervosa (Fairburn, Marcus, & Wilson, 1993) is considered the gold standard treatment for bulimia nervosa and binge eating disorder (APA, 2006). In this chapter, the authors review the CBT-E model for conceptualizing EDs, describe specific strategies for addressing disordered eating (i.e., normalization of eating, elimination of diets and binges), and provide cognitive strategies to assist the client with decreasing the importance of weight and shape in determining his or her worth and value.
Heather L. Waldron, Marian Tanofsky-Kraff, and Denise E. Wilfley provide in Chapter 14 a detailed overview of interpersonal therapy as adapted for working with clients with bulimia nervosa and binge eating disorder.
Interpersonal therapy has a strong evidence base regarding its effectiveness, shows both short- and long-term effectiveness for the treatment of bulimia nervosa and binge eating disorder, and has outcomes comparable to those of CBT. The authors assert that social problems contribute to an environment in which EDs are initiated and maintained, so if a client is able to increase healthy interpersonal skills and relationships, eating-related pathology will subsequently decrease. Throughout the treatment, clients are taught to link their eating symptoms to their interpersonal functioning and then to address current interpersonal problems in one of the following four areas: interpersonal deficits, interpersonal role disputes, role transitions, and grief. The authors provide an outline of the phases of treatment, detailing the goals and techniques used during each phase.
Although other chapters also address binge eating, in Chapter 15 Kerri N. Boutelle and Stephanie Knatz address treatments specifically developed for obesity and aberrant overeating patterns (i.e., regularly eating for reasons that are not motivated by biological hunger) in overweight or obese children and adolescents. Youths who engage in these eating patterns often lack the ability to regulate their food intake, resulting in binge eating, loss-of-control eating, emotional eating, eating in secret, and eating in the absence of hunger. Boutelle and Knatz describe these categories of overeating and then provide a summary of current treatment programs for obesity and overeating that are specifically designed to address these patterns.
Many clients with EDs experience comorbid concerns such as depression, self-injury, and substance abuse (APA, 2006). The presence of multiple client issues can complicate treatment, resulting in the need for interventions designed specifically for clients with multiple mental health concerns. In Chapter 16, Anita Federici and Lucene Wisniewski, researcher and clinical director, respectively, of a dialectical behavior therapy (DBT) program in Ohio, provide an overview of treatment challenges associated with clients who present with multidiagnostic and complex EDs, many of whom have not experienced success in other treatment programs. Federici and Wisniewski provide a rationale for the use of DBT with this population, based on its affect regulation model, therapeutic stance, prioritization of clients' multiple problem behaviors, methods for increasing clients' commitment to recovery, and techniques for managing therapy-interfering behaviors. The authors highlight the implementation of their structured DBT program, providing a specific description of the program components and counseling strategies used.
Because of its typical onset in adolescence and its high potential for life- threatening medical complications, anorexia often requires an intensive treatment approach involving the entire family system. In Chapter 17, Kim Hurst and Shelly Read provide an overview of family-based therapy, the treatment approach for anorexia in children and adolescents that has garnered the most research support (APA, 2006; Bulik, Berkman, Brownley, Sedway, & Lohr, 2007; Lock, LeGrange, Agras, & Dare, 2001). The authors review family systems theory that undergirds the family-based therapy approach, including the importance of the parental executive subsystem, the reduction of blame for the disorder, and the importance of including all family members in treatment. Hurst and Read provide a practical review of treatment phases included in family-based therapy, applying the components to a case example that is woven throughout the chapter.
In the book's final chapter, Chapter 18, Heather Trepal, Ioana Boie, Victoria Kress, and Tonya Hammer review relational-cultural therapy, a feminist approach to treatment that posits that the foundation of development is connection and context, not individuation (Jordan, 2010). Relational-cultural therapy aims to heal chronic disconnection, which is proposed to be at the heart of many mental disorders, including EDs and excessive eating that can often contribute to obesity. The authors apply relational-cultural therapy's relationally focused strategies for working with clients with eating- and weight-related concerns and provide approaches for both prevention and treatment.