Running Head: TREATMENT PLAN for ANOREXIA NERVOSA
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Treatment Plan 1
Running head: TREATMENT PLAN FOR ANOREXIA NERVOSA
Treatment Plan For
Anorexia Nervosa Restricting Type
Jane Wallis Turnbull Treatment Plan 2
Peggy has been referred to me after seeking treatment at her College Counseling
Services. She has recently been discharged from an intensive inpatient eating disorder program.
She is required to remain in treatment and maintain her goal weight or she will be committed back into the hospital.
Peggy has a history of Anorexia Nervosa, Restricting Type and has been hospitalized twice. She did well with treatment the first time, until she went off to college. The demands of college such as academics and social stressors resulted in her restricted eating behaviors all over again. Therefore not only will I as the counselor need to help her focus on the stressors that go along with having an eating disorder yet also help her focus on how to cope with the demands of college life as well.
Peggy is an upper-middle class twenty-year old African American female. She originally began a diet four years ago but this diet resulted in her developing anorexia nervosa. As stated earlier, she was treated and did well with treatment until she went off college. She has typical compulsive eating habits of anorexia nervosa such as: cutting food into small pieces, moving food around on the plate and eating very slowly. She also was compulsive about what foods she would allow herself to eat. For example she restricted herself from eating foods that were high in fat or carbohydrates. She also presented fear of becoming fat. Her anxiety increased as she looked at herself in the mirror. Peggy meets all of the criteria for anorexia nervosa. She has never presented any signs of binge or purging therefore she is diagnosed as Restricting Type.
Peggy is not diagnosed with Obsessive Compulsive Disorder because her compulsive behavior and obsessive fears of being fat are listed under the criteria for anorexia nervosa.
Peggy has been treated twice through i.npatient intensive individual and family treatment.
It does not state this in the case but I assume through the descriptions given that she has had Treatment Plan 3
Cognitive-Behavioral treatment in the hospital and of course Family Therapy as stated before.
The Behavioral treatment consisted of gaining two pounds per week or she was put on bed rest.
Another form of Behavioral treatment dealt with her anxiety, in which the therapist had her look at herself step by step in the mirror until the fear went away or decreased. The Cognitive part of therapy consisted of the reframing her maladaptive thoughts of “being fat” and body distortion.
Being that Eating Disorders are a family Disorder I was glad to note that she has also received
Family Therapy which can often be overlooked as an important part in treating people with this form of mental disorder. (Lock, Grange, Agrus & Dane, 2001 p. 13-14)
Although the case describes all of the methods of treatment and assessment necessary for the treatment of Anorexia Nervosa, it did not mention group therapy. Group therapy may have complications when it comes to eating disorders, especially anorexia nervosa due to the competition aspect of the disorder. However the positive outcomes that result from Group
Therapy usually outweigh the negative. “Especially for those who have had the disorder for several years, there seems to be a ray of hope as they talk with patients who have been able to make noticeable progress under similar circumstances.” (Gross, 1982 p. 114) I feel Peggy being that she has relapsed before can benefit from seeing the struggles others have had and how they overcame it.
The rationale of diagnosing Peggy with Anorexia Nervosa, Restricted Type has been somewhat illustrated earlier in the treatment plan. However the specifics of how she meets the criteria are as follows: she presents a refusal to maintain body weight at or above a minimally normal weight for her age and height; she has an intense fear of gaining weight or becoming fat, even though under weight; she shows a disturbance in the way in which her body weight or shape is experienced; she has a history of amenorrhea. Peggy was diagnosed as Restricting Type Treatment Plan 4 because she did not regularly engage in bing-eating or purging behavior such as: self-induced vomiting, misuse of laxatives, diuretics or enemas.
The treatment goals consist of: Peggy maintaining goal weight prescribed by hospitalization; decreasing compulsive behavior; decreasing poor body image and fear of gaining weight; and lastly decreasing anxiety of the demands of college. These goal of course will be encouraged but only once Peggy realizes them for herself, with the exception of maintaining goal weight.
Cognitive Behavioral Treatment (CBT) has been shown to work with all types of eating disorders. However, this type of treatment works best with those suffering from bulimia nervosa. Because anorexia nervosa patients have rigid views and behaviors they resist treatment more then bulimia nervosa clients, which is why CBT is not successful at times. Through my research of CBT versus Behavioral treatment alone there were no differences in outcomes of success. However, I feel there needs to be more studies of the long-term results of CBT with anorexia nervosa. My prediction would be that the cognitive aspects of CBT would help decrease the chance of relapse. (Wilson & Fairburn, 1993 p. 263)
Family Therapy is another form of treatment for anorexia nervosa. “Family Therapists think about the development of an eating disorder as a signal that the family is under stress.”
(Kinoy, 2001 p57) This statement is not saying that one should blame the family, because eating disorders are much too complex to view it that simply. Due to the fact that eating disorders are so complex the family can at least help in becoming change agents. The family structure will need to change in order for the client to implement changing her eating disorder patterns. (2001 p. 58-59) Eating Disorders are a result of many factors yet lack of control is the central theme. If the client feels they have more control over their life and their role in the family then change can Treatment Plan 5 occur. Therefore the families role in recovery is extremely important. “Feminist theory has added a critical perspective on some of the structural and strategic approaches to family therapy that emphasize the therapist’s hierarchical relationships to the patient and family.” (Lock,
Grange, Agras & Dare., 2001 p. 15) Family Therapy is a successful way to help in the recovery process of eating disorders.
Group therapy can be beneficial in the treatment of anorexia nervosa for many reasons.
As stated earlier, Group therapy may have negative side effects because of the competitive edge anorexia nervosa clients develop. However, it presents many educational opportunities, decreases anxiety of fear from developing the disorder further. For example, “Discussion of hospital experience seems to encourage some patients to remain outside the hospital and provides further motivation for successful outpatient treatment.” (Gross, 1982 p. 115) On the other hand the group therapy can provide a sense of assurance that the inpatient treatment is not as scarey as it seems so that those entering may have a decrease in anxiety. As with any disorder, meeting others who are struggling similarly to you, can bring about less stress and more motivation to recover. (1982 p. 111-116)
In the treatment of Peggy’s Anorexia Nervosa I will begin with Cognitive- Behavioral
Treatment which I will: incorporate self-monitoring techniques (food journal); continue with cognitive restructuring (with the mirror techniques that they used in the hospital) of maladaptive body image and fears of gaining weight. Due to the fact that those suffering from anorexia nervosa present rigid behaviors I will have her do a food journal for only a month so that this too does not become a compulsion. Also I will at first meet with her twice a week in the beginning, because she just was discharged from the hospital and needs to weigh in regularly. I will eventually weigh her randomly to ensure that she is in good health. If she gets below her goal Treatment Plan 6 weight at any time I will encourage her to go back into inpatient treatment. If she refuses then I will have her committed. Of course this will all be explained to her in great detail at our first session. To lower her stress of her college demands I will educate her about stress management and time management techniques. I will do this by teaching her breathing techniques and how she could realistically use a calendar effectively. Also I will use assertiveness skills to help her gain the confidence to say “No!” to things so that she can manage her time better. By learning to assert herself she can devote more time to herself and her studies.
I will also implement Family Therapy not only because eating disorders are a family disorder yet also because of the fact that she lives at home with her parents still. “...Russell et al.
(1987) found that older patients did better with individual therapy compared with family therapy.” (Lock et al., 2001 p. 22) This may be true, however the fact that she still lives with her parents makes her an exception. I will have therapy with Peggy and her family once every two weeks in the beginning in order to educate her family on how to become change agents and to further avoid relapse.
I will also have Peggy attend an eating disorder group therapy once a week at first and then once every two weeks. I will encourage her to continue this even after our therapy is terminated. I will show her that even if she is successful in her treatment, there is an importance in continuing group therapy because in helping others she in turn will be helping herself.
I will also refer her to a nutritionist in which she will be further educated on food and hopefully end her myths about food. Although Peggy is a majoring in nutrition, she still has personal myths about what food does to her body, therefore some one on one consultations from a nutritionist will be beneficial. Anorexia nervosa is very complex and this therapy process will be long and require a lot of patience. As long as Peggy is actively working toward her goals of Treatment Plan 7 seeking mental and physical health this treatment plan will be successful.
The long term goals for Peggy include: maintaining healthy body weight; to successfully continue to remain in school; a decrease in body distortions, rigid restricting eating behaviors; and adopting a healthier view of nutrition. Not only is the long term goal to stay healthy, but to work on avoiding relapsing again by obtaining the skills necessary to avoid relapse. Of course relapse is very common among those suffering from eating disorders so my goal as a counselor will not only to help Peggy learn to avoid this, yet to learn the skills necessary in dealing with the reality of relapse. For example, cognitive skills, that would decrease the guilt that goes along with the relapse process.
The short term goals for treatment of Peggy’s Anorexia Nervosa, would be to first and foremost maintain a healthy body weight. Without the proper nutrition to her body and brain therapy cannot be successful. (Matthews, 2001 p. 52-53) Due to the fact that to life after an eating disorder is a long process the short term goal is to develop a trusting, safe therapeutic relationship with Peggy. “In AN patients, recovery is a long process. Treatment planning should anticipate this and take the phase of illness of the individual patient into consideration.” (Herzog,
1997 p. 177) The short term goal will also be to motivate Peggy to actively participate in the many forms of therapy that will be provided ,(Cognitive-Behavioral Therapy, Family Therapy,
Nutrition and Psychoeducation and Group therapy), and to develop a desire in wanting to reach her goals.
Peggy’s social support through reviewing her history consist of two parents with whom she currently lives with. Her parents are still married and through an initial evaluation of them, they seem to be very willing to help in her recovery process in anyway that they can. Peggy also has a little brother who is seventeen and through my initial observation of them and through Treatment Plan 8 comments from Peggy, they seem to be very close. Therefore, her family support is very high and my prediction is that they will desire becoming change agents for the betterment of Peggy.
Due to the fact that Peggy has suffered from anorexia nervosa for many years now, she has isolated herself from forming close friendships. Her friend base is not very high and this will be something to focus on in therapy.
Peggy is an African American female which presents two forms of oppression. Her culture is a collectivist culture unlike the majority culture which is individualistic. (Ponterotto,
Casas, Suzuki & Alexander, 1995 p. 34-36) Some therapist because of the fact that she is twenty and still lives at home, may encourage her to move out. Especially because this is a family disorder this may be looked at as an option. However I realize as a counselor I can not assume that this is what is good for the client. Peggy’s main support seems to be her family at this point in time and culturally moving out may not be an appropriate option for her. Through researching the cultural aspects of eating disorder as it relates to minority populations I found that because of oppression and stereotypes not much research has been done. In our society we are socialized to believe that eating disorders only happen to upper-middle class females, however this is not the case. (Lester & Petric, 1998 p. 315-321) “The traditional European
American Standards of attractiveness and beauty may be experienced as oppressive for many women, but particularly for women of color whose own body standards are not drawn from the
European American Culture.” (Harris & Kuba, 1997 p. 343) Through psychoeducation of eating disorders the cultural component will be discussed with Peggy throughout treatment.
The severity of anorexia nervosa is a major factor in treating Peggy. As a counselor I will need to make sure she maintains a healthy body weight and periodically check her blood pressure. If she develops extreme loss of weight and or extreme maladaptive eating patterns Treatment Plan 9
(restricting/binging/purging) then referring her to an inpatient treatment facility is a must.
Anorexia nervosa is one of the deadliest mental disorders there is. “Mortality rates for anorexia nervosa vary from 5 to 20 percent.” (Matthews, 2001 p. 55) In the therapy process the severity of this mental disorder will not be taken lightly.
The modes of treatment for Peggy as discussed earlier will consist of Cognitive-
Behavioral therapy, Family Therapy, Psychoeducation of eating disorders, Nutritional education and Group therapy. Each of these forms of treatment are equally important and all of them combined will hopefully result in a high success rate for recovery for Peggy. (Kinoy, 2001 p
162-164) Medication for the relieving of anxieties and depression that may occur as a result of anorexia nervosa can be an option for Peggy. After a period of time if I feel this is necessary, I will refer her to a psychiatrist for further evaluation in order to determine if antidepressants or other psychiatric medications might be necessary. (Matthews, 2001 p. 178) I will keep in mind however the research on psychiatric medications in relations to anorexia nervosa. They have been more successful with bulimia and I will note this in Peggy’s case. “Despite what many think, anorexia nervosa has so far been shown to be relatively resistant to treatment with drugs.”
(Costin, 1999 p. 219) I will also encourage Peggy to see her primary care physician, which will be very important due to the many physical components that go along with having an eating disorder. (Gross, 1982 p. 15-24)
My prognosis of the treatment of Peggy’s anorexia nervosa solely depends on her willingness to participate in the therapeutic process. If she is motivated to change and her family becomes sucessful change agents then her outcome should be positive. “The prognosis for anorexia nervosa is poor.” (Matthews, 2001 p. 55) However, because of her family support and no history of purging behavior there is a greater chance for recovery for Peggy. (Hezog, Treatment Plan 10
Schellberg & Deter, 1997 p. 169)
In evaluating the treatment effectiveness of anorexia nervosa, restricting type I will have her come to follow-up visits and eventually stay in contact with her by phone. I will also encourage her to go to her primary care giver annually, who will know her history of anorexia nervosa. With permission from Peggy, her primary care physician will notify her family and me if her weight or eating behaviors become alarming again. Treating eating disorders involves a lot of patience from both the client and the therapists. As long as Peggy is willing to work at it treatment for her anorexia nervosa will be possible.
References
Anderson, A. E. (1985). Practical Comprehensive Treatment of Anorexia Nervosa and Bulimia.
Baltimore, MD: The Johns Hopkins University Press.
Costin, C. (1999). The Eating Disorder Sourcebook. Los Angeles, CA: Lowell
House.
Gross, M. (1982). Anorexia Nervosa A Comprehensive Treatment Approach. Lexington, MA:
The Collamore Press.
Harris, D. J., & Kuba, S. A. (1997). Ethnocultural Identity and Eating Disorders in Women of
Color. Professional Psychology: Research and Practice, 28, 341-347. Treatment Plan 11
Herzog, W., Schellber, D., & Deter, H.(1997). First Recovery in Anorexia Nervosa Patients in
the Long-Term Course: a Discrete-Time Survival Analysis. Journal of Consulting and
Clinical Psychology, 65, 169-177.
Kinoy, B. P. (2001). Eating Disorders (Second Edition) New Directions in Treatment and
Recovery. New York, NY: Columbia University Press.
Lester, R. & Petrie, T. A. (1998). Physical, Psychological and Societal Correlates of Bulimic
Symptomatology Among African American College Women. Journal of Counseling
Psychology, 45, 315-321.
Lock, J., Grange, D. L., Agras, W. S., & Dare, C. (2001). Treatment Manual for Anorexia
Nervosa. New York, NY: The Guilford Press.
Matthews, D. D. (2001). Eating Disorder Sourcebook (First Edition). Detroit, MI: Omnigraphics
Inc.
Nasser, M., Katzman, M. A., & Gordon, R. A. (2001). Eating Disorders and Cultures in
Transition. New York, NY: Taylor & Francis Inc.
Ponterotto, J. G., Casas, J. M., Suzuki, L. A., & Alexander, C. M. (1995). Handbook of
Multicultural Counseling. Thousand Oaks, CA: SAGE Publications, Inc.
Stierling, H., & Weber, G. (1989). Unlocking the Family Door. New York, NY: Brunner/Mazel
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