Biopsychosocial Assessment

 The information provided has been obtained through _______________. This client will be referenced for the purposes of this paper as Karen in order to maintained confidentiality. Karen, 31 years-old sales clerk, presented for treatment for binge eating disorder. At intake she reported three binge episodes a week, during which she consumed an unambiguously large amount of food (typically three to four fast-food sandwiches within a half hour) and felt a loss of control. She reported being most likely to binge eat when feeling uneasy, and stated that her overeating caused her marked distress.

Karen’s binge eating began at age fifteen and had been followed by years of dieting and weight fluctuations. At 231 pounds, she was severely overweight, above the ninety-fifth percentile of weight for her age and height. She had an extreme fear of weight gain and great discomfort in allowing herself or others to see her body.

Karen had a history of avoiding conflict and a fear of criticism. At the age of fifteen, she began a series of failed relationships that she had attempted to hide her parents or to glorify (saying, for example, that she was married when she wasn’t) in order to appear the “perfect” daughter and to not disappoint her parents. She binged when she was alone and used food to “numb out” in order to manage the feelings that she kept private. 11er attempts at secrecy and use of food to disconnect from her feelings continued throughout Karen’s subsequent marriage. Although her husband had been cruel and verbally abusive, Karen worked hard to “fool everyone for eighteen years” into believing that she had a fulfilling relationship because she didn‘t want anyone to think that she had failed in her marriage.

Since her divorce, Karen had been in a live-in relationship but remained emotionally disconnected from her boyfriend. She concealed her eating disorder from him, ate very little when they were together, and continued to binge eat when alone. At work, Karen reported that she put in fourteen-hour days because she felt uncomfortable “saying no“ to customers’ requests to see her before and after their business hours. Given the long periods of time she spent on her feet without breaks to eat or rest, Karen clearly disregarded her needs to an extreme degree. Consequently, she found herself binge eating at night, often on her way home from work, to avoid the conflictual feelings she had about experiencing resentment and frustration over her workload.

 Karen had never been in therapy before. Although she indicated a preference for CBT, she was randomly­ assigned to the interpersonal therapy group as part of a binge-eating disorder psychotherapy treatment trial. Before the group sessions began, she met with her fao-therapists for a two-hour pregroup meeting. In group IPT, this pregroup meeting parallels the early sessions of individual IPT, eliciting a detailed inventory of the patient’s interpersonal history and formulating problem arcas and goals to guide the therapeutic work.

During this initial session, Karen was given her diagnosis and assigned the “sick role.” She was also educated about binge eating disorder and reassured that it was the eating disorder, rather than a lack of motivation on her part, that was driving her incrementa] weight gain and out-of-oontrol eating. After learning about her current symptoms by discussing a recent episode, Karen’s therapists skipped back to her very binge, using this as a frame through which to move forward chronologically. Together she and her therapists constructed a profile of relationship difficulties involved in the onset and maintenance of her binge eating.

Karen and her therapists examined the use of binge eating as a primary coping strategy to manage her negative affective states and avoidance of conflict. Given lier historyr of unfulñlling relationships and inability to manage her feelings interpersonally, Karen was assigned the problem area of interpersonal deficits.

To target her problem area, Karen was given three goals related to both her binge eating and lier work resolving problems with interpersonal deficits. First, Karen was directed to become more

aware of and to learn to identify her feelings when she began to binge eat or feel out of control with her eating. Many people who struggle with binge eating have difficulty identifying and labeling their affective states. Learning to do this would give Karen an extremely useful tool with which to begin to eliminate her binge episodes and, in a preliminary way, to help increase her connections with others. Second, she was encouraged to begin expressing her feelings with others-especially her boyfriend-rather than trying tc avoid potential oonilict. Years of lying to important people in her life and to herself to maintain an image of perfection had left Karen unable to communicate effectively or manage conflict. As a goal, Karen was instructed to ways to nurture herself rather then spending al] of her energy caring for others. Consistent with her problem area, Karen had established a relationship pattern,

common among binge eaters, of excessive caretaking for others. Karen was encouraged to take better care of herself in order to break the vicious cycle of self-denial that she had established in her signiñcant relationships. 1n addition, focusing on herself in relationships would also teach Karen about more effectively­ negotiating her interactions. Given the link between her problem area and binge eating, Karen’s therapists explained that the exclusive focus on these goals would eliminate her binge eating. ‘foward the end of the interview, the therapists helped prepare Karen for the work of the group and addressed her concerns about oonfidentiality. Her individual goals were linked to the group work by encouraging her to think of the group as an “interpersonal laboratory” where ties to others could develop, naturally occurring “impasses” in the formation of intimate relationships oould be examined, and new approaches to handling interpersonal situations could be tried out. Karen was also instructed that the main focus of the group was to help her appl),r the skills learned in the group to her outside social life.

During the first phase of treatment, work with Karen centered on helping her connect her binge eating to difficulties in relationships. Consistent with a problem area of interpersonal deficits, Karen had initiating contact with other group members. In early sessions, she made comments that distanced herself from the group, such as stating that she was unlike the others because she had wonderful relationships, and had no problems to speak of other than her inability to diet effectively. A turning point eame when group members began to explore their own unsustaining relationships. This group dialogue helped Karen realize that her relationships had not been as intimate or satisfying as she had first indicated.

Outside the group, Karen worked on the goal of caring for herself and expressing more feelings to her boyfriend. Having reduced her workload and become more physically active, Karen announced that she was feeling better about herself.

Throughout the second phase of treatment, Karen worked on goals in her outside life. Her therapists encouraged her to notice her style of glossing over problems, and Karen continued to receive helpful feedback about minimizing her feelings. As Karen spoke about her unhappiness during her first marriage, she began to understand that maintaining the facade of a perfect life prevented her from turning to others for assistance. Discounting her own feelings generally prevented her from experiencing her emotions or addressing them in adaptive ways. The progression of the group through the conflict phase of treatment further provided Karen with opportunities to observe that conflict could be worked through effectively. She was often surprised at the open discussions group members had with one another. Although discord made Karen very anxious at first, the successful rcsolution of a few instances of friction among group members helped her to see that disagreements oould have positive outcomes and could even strengthen relationships. Outside of the group, Karen began discussing her feelings openly with her sisters, communicating with coworkers, and setting limits with customers by refusing some of their requests.

By the last phase of treatment, Karen was aware of the enormous energy she had spent concealing her problems. She was more open with her friends and family. She reported her relationships were more satisfying, and she and her boyfriend had become engaged. She continued to decrease her work hours and by the end of treatment had begun frank discussions with her daughters about their unresolved feelings about their father. Having learned to recognize her emotions and to make more time for herself, Karen was able to attend to negative feelings “without feeling as if the world was coming to an end.” Karen had stopped binge eating by the time the phase of treatment began. At post-treatment, she set the goal of giving more thought to conflict when it occurred rather than waiting for it to go away. At eightmomh follow-up, Karen had lost Seventy pounds from her initial assessment weight and remained binge-free..

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