Section 4 ffective Treatments for Eating Disorders and Obesity
Enhanced Cognitive-Behavioral Therapy Approach to Counseling Clients With Eating Disorders
Anthea Fursland and Hunna J. Watson
In this chapter, we introduce counselors to an evidence-based treatment that can be applied to all eating disorder (ED) diagnoses in adults. Enhanced cognitive-behavioral therapy (CBT-E) is a relatively new treatment that has shown promising results in research and community settings.
Why Do Counselors Need to Know About Eating Disorders Treatment?
Treatment of EDs is notoriously difficult, and many counselors are hesitant to treat people with such conditions, especially those with anorexia nervosa (AN) because of the high prevalence and seriousness of medical comorbidities. Bulimia nervosa (BN) also carries health risks, and atypical variations of these diagnoses (eating disorder not otherwise specified, or EDNOS) have similar levels of morbidity and pathology to AN and BN (Fairburn et al., 2007; Ricca et al., 2001). AN, BN, and EDNOS are the three categories of EDs recognized in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000). Binge eating disorder is currently categorized as a form of EDNOS, although inclusion as a standalone ED in its own right is anticipated in the forthcoming fifth edition.
It is widely accepted that EDs, especially AN, are relatively rare. Yet recent population studies have shown that they are more prevalent than previously thought, with one study showing lifetime prevalences for AN and atypical AN of 2.2% and 4.2%, respectively (Keski-Rahkonen et al., 2007).
Approximately 15% of women will need clinical treatment for a diagnosable ED in their lifetime (Wade, Bergin, Tiggemann, Bulik, & Fairburn, 2006). Although it has been accepted that only 10% of individuals with AN or BN are male, a recent community study of more than 10,000 teenagers found equal numbers of male and female teens with AN (Swanson, Crow, Le Grange, Swendsen, & Merikangas, 2011).
Furthermore, unhealthy weight control methods, including disordered eating, are common (Neumark-Sztainer, Wall, Larson, Eisenberg, & Loth, 2011), and behaviors falling under the criteria for EDNOS are increasing among men and women (Hay, Mond, Buttner, & Darby, 2008; White, Reynolds-Malear, & Cordero, 2011). Counselors working in general practice settings will likely encounter adults with disordered eating and full-syndrome EDs, even if these clients were referred for other reasons. In fact, many individuals with EDs do not disclose the ED and instead seek help from health and mental health professionals for related issues or secondary consequences of the ED (e.g., depression, anxiety, gastrointestinal problems, weight loss). The low rate of help seeking among people with EDs stems from many factors, such as shame and poor self-recognition of disordered eating. It is thus incumbent on all counselors to screen for and be prepared to treat EDs (see Chapter 5, this volume). A useful tool for screening EDs is the five-question SCOFF questionnaire (Morgan, Reid, & Lacey, 1999), which is akin to the CAGE for screening alcohol problems:
1. Do you make yourself vomit because you feel uncomfortably full?
2. Do you worry you have lost control over how much you eat?
3. Have you lost over 14 lbs. in a three month period?
4. Do you believe yourself to be fat when others say you are too thin?
5. Would you say that food dominates your life? (Morgan et al., 1999, p. 1467)
(Two or more “yes” answers are suggestive of possible anorexia nervosa or bulimia nervosa and indicate the need for further questioning.)
Being alert and ready to respond to EDs can be a very professionally rewarding experience and bring substantial scope to counselors to contribute meaningfully to clients' long-term physical and mental health.