Intermediate Intervention: Responding to Moderate Client Needs
Intermediate intervention is implemented when a problem exists, causes moderate difficulties, and has the potential to grow, which means that practitioners rely on intermediate interventions with clients for whom ED symptoms are emerging or are currently being experienced but are as yet only modest or do not meet the criteria for a diagnosable ED. In turn, we suggest clinicians cast a wide net when identifying clients in need of intermediate ED intervention. Specifically, counselors should consider engaging their new, current, or ongoing female clients in intermediate interventions targeting the emergence of ED symptoms whenever their clients
• present with symptoms such as extreme dieting, excessive exercise, episodic binge eating, or occasional compensatory behaviors (e.g., vomiting or laxative use and diuretic misuse);
• express particular pressure to become thin and appear to heavily endorse the cultural thin ideal as their own standard for measuring their self-worth;
• are exposed to family members with body image and eating problems;
• appear to lack family and peer social support; and
• present with low self-esteem, negative affect, and problematic perfectionism (Choate & Schwitzer, 2009; Fairburn, 1995).
At the intermediate intervention level, clients usually express minimal motivation for change (Drum & Lawler, 1988). Therefore, intermediate counseling approaches aim to minimize client resistance, increase client engagement, and focus mostly on adding new skills to, building new dimensions into, and boosting resiliency factors in the individual's life. Brief or minimal individual counseling and an emphasis on group formats is recommended (Drum & Lawler, 1988). In other words, although individual counseling may also be needed, at the intermediate level short-term group counseling primarily is recommended as a treatment of choice (Choate & Schwitzer, 2009).
Intermediate-level group interventions for eating concerns should generally combine psychoeducational and cognitive-behavioral components (Choate & Schwitzer, 2009).
Intermediate ED counseling groups also capitalize on the benefits of social support among peers who might otherwise lack support in their natural interpersonal environments; create an ameliorative sense of universality with other girls and women confronting similar eating-related and body image struggles; and create interpersonal environments for learning new ways of coping (Stice, 2002; Stice & Hoffman, 2004). Moreover, groups can be used as efficient formats for providing topical information and new learning about self (Brown, 2011).
Psychoeducation and Intermediate Intervention When counseling group leaders provide psychoeducation, they should include themes such as the social-cognitive aspects of the thin ideal, especially as it is presented in societal media images portraying idealized female beauty; how the thin ideal and its portrayal in the media promote inappropriate and unrealistic standards for self-comparison, leading to poor self-evaluations unduly influenced by ones body image; and similar themes about beauty and womens self-esteem. Here, having group members realize the unattainability of the thin beauty ideal and recognize the role of media can serve as buffers against the negative influences of these factors (Coughlin & Kalodner, 2006; Yamamiya, Cash, Melnyk, Posavac, & Posavac, 2005). Furthermore, these groups can provide nutritional, eating, and weight management information emphasizing health promotion and use activities and homework leading to lifestyle changes (Stice, Gau, Presnell, & Shaw, 2007).
Cognitive-Behavioral Strategies and Intermediate Intervention When counselors use cognitive-behavioral strategies, EDNOS group members are generally challenged to change their beliefs and attitudes about the importance of weight and body shape on their self-evaluations and approval of self (Matusek, Wendt, & Wiseman, 2004; Stice, 2002; Yamamiya et al., 2005). More specifically, dissonance-based cognitive interventions are recommended. Dissonance-based strategies are based on the assumption that clients with intermediate needs have already internalized the thin ideal. On this basis, outcome goals are to heighten awareness about the cultural sources of the ideal, create cognitive dissonance and tension by encouraging clients to resist the ideal, and, in turn, lead to behavior change (Stice, Chase, Stormer, & Appel, 2001; see also Chapter 10, this volume). Clinicians can use role-plays, persuasive arguments, and other methods of cognitive confrontation to achieve these outcomes.