Integrating Eating Disorders Assessment Into an Unstructured Clinical Interview
Clinical interviews require counselors to balance the dual goals of obtaining a comprehensive assessment with developing and maintaining rapport with the client (Peterson, 2005). Given the serious medical and psychiatric complications associated with EDs (Academy for Eating Disorders' Medical Care Standards Task Force, 2011; Crow & Swigart, 2005), it is important for counselors to assess ED symptoms with all clients regardless of age, gender, race or ethnicity, or weight status. However, in general outpatient clinics, a comprehensive ED assessment may not be necessary or feasible. Therefore, we recommend that counselors conduct a screen for ED symptoms and follow up with a more comprehensive assessment if necessary.
Screening for Eating Disorders
Unstructured clinical interviews that include assessment of general self- care lend themselves easily to ED screening. Specifically, questions about sleep and eating patterns can provide an effective segue into an ED screen.
General questions about a client's eating patterns such as “What is your general eating pattern?” and “Do you ever skip meals?” can introduce the topic of disordered eating behavior without causing initial discomfort. Counselors may choose to follow up with questions about the client's diet history (e.g., “Have you ever been on a diet?” “What kinds of diets have you tried?”) and patterns of dietary restriction (e.g., “Are there any foods that you like that you're trying to avoid eating?” “Do you try to follow any rules regarding your eating?”). These questions can then lead into more specific questions about disordered eating behaviors such as binge eating (e.g., “Have you ever felt a sense of loss of control over your eating?”) and compensatory behaviors (e.g., “Have you ever done anything to compensate for food you've consumed such as self-induced vomiting or laxative use?”).
Questions about exercise may also be included in an unstructured interview in the context of assessing clients' self-care. The addition of several detailed questions regarding the quantity and quality of exercise can also provide information regarding the client's propensity for excessive exercise and disordered eating behaviors. If a client endorses exercise, it is recommended that counselors ask detailed questions about the type (e.g., “What kind of exercise do you typically do?”), duration (e.g., “On average, for how long do you typically exercise?”), and intensity (e.g., “How intense is the exercise you usually do?” “Do you ever feel that you exercise beyond what is physically healthy for you?”). The DSM-IV-TR and DSM-5 describe problematic or disordered exercise as “excessive exercise”; however, determining what qualifies as excessive exercise can be difficult. For example, although frequent and intense exercise may reflect an underlying ED, these types of activity patterns may or may not be problematic in the context of athletic training. Research has suggested that the qualities of exercise that best differentiate normative exercise from disordered exercise are the following: (a) The exercise is motivated solely or primarily by shape or weight concerns and (b) feelings of guilt when exercise routines are not completed (Mond & Calogero, 2009; Mond, Hay, Rodgers, & Owen, 2006). Counselors may also choose to determine the extent to which the individual feels driven or compelled to exercise, whether exercise is completed even when the individual is sick or injured, and whether exercise is completed at the expense of other activities or commitments.
Finally, general questions about self-esteem, such as “How do you feel about yourself as a person?” can lead to more specific questions about body image, such as “Do you ever feel dissatisfied with your shape or weight?” These types of questions can be used to assess body image disturbance or overevaluation of shape and weight, which may be indicative of an ED.