Counseling Women with Bulimia Nervosa

Counseling Women Diagnosed with Bulimia Nervosa
Student ID: 18104894
CNS ED 6000
November 12, 2012

Counseling Women Diagnosed With Bulimia Nervosa
Katie Andrews

Abstract
This literature review will introduce bulimia nervosa and discuss research that pertains to counseling women who seek treatment for this particular eating disorder. The information included will be helpful for counselors and those seeking help for bulimia or for a loved one. This paper addresses matters that cause and compound bulimic pathology, such as exposure to western culture and deficient emotional regulation. It also outlines several counseling modalities that benefit the population. Cognitive Behavioral Therapy (CBT) and its variants, Interpersonal Therapy (IPT) and Dialectical Behavioral Therapy (DBT) are therapies that benefit female bulimics, as evidenced by empirical support. This paper touches on two Mindfulness-based adjunctive interventions. Mindfulness-Based Cognitive Therapy (MBCT) and Mindfulness-Based Eating Awareness Training (MB-EAT) also benefit the female bulimic population, as evidenced by phenomenological research.
Introduction
Bulimia nervosa is characterized by episodes of binge-eating behavior followed by compensatory behaviors (such as self-induced vomiting, laxative abuse, restrictive eating and/or excessive exercise), which are designed to control the body and the emotional internal world (Broussard, 2005; Johnson & Connors, 1987; Wilson & Shafran 2007). The disease primarily affects “urban, upper- and upper-middle class, mid-to-late adolescent white females,” living in the context of “western industrial, capitalist nations,” (Bendfeld-Zachrisson, 1992). Clinical trials reflect a prevalence of bulimia in women between 1 and 20 % of the entire population (Bendfeld-Zachrisson, 1992). While men suffer from bulimia, the disease is principally associated with females (Johnson et al., 1987).
Research reflects that bulimia presents as a chronic and self-perpetuating condition (Fairburn, 2008; Wilson et al., 2007). Wilson et al (2007) studied women who seek treatment for bulimia and found that bulimia is among the most difficult psychological disorders to treat. He explains that remission is commonly transitory and relapse happens frequently. Even the most successful treatment modalities fail to offer a female client long-term healing from her eating disorder (Wilson, 2007).
Nevertheless, research shows that an enhanced form of Cognitive Behavioral Therapy (CBT-E), Interpersonal Therapy (IPT) and Dialectical Behavioral Therapy (DBT) each illustrate empirical effectiveness in the context of treating the distorted thoughts, interpersonal struggles and emotional distress that maintain bulimic behavior (Fairburn, 2008; Kristeller, Baer & Quillian-Wolever, 2006; Mitchell, Agras & Wonderlich, 2007). Furthermore, pieces of mindfulness-based phenomenological research underscore the significance of cultivating awareness within the bulimic population, which can be integrated by means of Mindfulness-Based Cognitive Therapy (MBCT) and Mindfulness-Based Eating Awareness Training (MB-EAT) (Kristeller & Wolever, 2011; Kristeller et al, 2006).
Causality and Features that Influence Bulimia Nervosa
Johnson et al. (1987) conducted research on the etiology of bulimia; they state that any conceptualization of causality is much too limited a view on the etiology of bulimic behavior. Still, research shows that exposure to western culture and emotional dysregulation are two significant causal features that perpetuate the disorder (Bendfelt-Zachrisson, 1992; Schupack-Neuberg & Nemeroff, 1992; Stice & Shaw, 1994).
Societal and Cultural Influences
Bendfeldt-Zachrisson (1992) discusses how culture is an agency responsible for bulimic behavior. He deliberates that a woman’s preoccupation with her ability to force her body to conform to western culture’s “dominant beauty [norm]” can cause bulimic reactivity. Conversely, he states that a woman’s binge-eating behavior can be conceptualized as her rejection of western culture’s body-ideal. In both scenarios, the sociocultural macrosystem “permeates the [woman], becomes internalized,” and finds expression by means of bulimic behavior.
Stice and Shaw (1994) conducted a study that expands on Bendfeldt-Zachrisson’s discussion about bulimia’s social-conforming function. They found that a woman’s desire to achieve the ideal body-type is a predictor of the development and maintenance of bulimia nervosa. Furthermore, their study reflects how exposure to the “perfect” female body causes social comparison, low self-esteem, body dissatisfaction, affective disturbance, decreased self-confidence and increased “endorsement of the thin-ideal sterotype,” which perpetuates all aforementioned toxic results. The listed effects of being exposed to the thin-ideal influence, predict and maintain eating disorder pathology; thus, they must be attended to in the recovery process (Stice et al., 1994).
Emotional Dysregulation
Johnson and Connors (1987) state that most bulimic women are alexithymeic, which means that they have difficulty labeling and regulating their emotions. Schupack-Neuberg and Nemeroff (1992) notice that instead of coping with emotionality in an adaptive manner, a bulimic woman will squander emotions via binging and compensation. Specifically, the binge obliterates emotional-awareness and the purge metaphorically expels negative affect.
Using binge-eating behavior to ameliorate emotional distress reinforces a woman’s maladaptive perception that her bulimic behavior has curative qualities (Kristeller et al., 2006). Even though these behaviors are physically harmful, the counselor must be mindful that they may be ego-syntonic for his/her client’s emotional experience (Goss et al., 2010; Kristeller et al., 2006). Therefore, a bulimic woman’s affective disorder is a condition within the eating disorder that must be rehabilitated if she is to achieve holistic recovery (Goss et al., 2010; Johnston et al., 1987; Kristeller et al., 2006; Schupack-Neuberg et al., 1992).
Counseling Strategies
CBT-E and Related Cognitive-Behavioral Therapies
Fairburn (2008) claims that bulimia is fundamentally a disorder of cognitive functioning, which means that CBT-E is the ideal treatment modality as it focuses on shifting maladaptive thinking. Currently, an enhanced form of Cognitive Behavioral Therapy (CBT-E) is the leading treatment modality for bulimia nervosa (Fairburn, 2008). Based on empirical research, CBT-E is effective because a client’s positive or negative response within the first stage of CBT-E treatment predicts her ultimate positive or negative response to treatment in general, respectively (Fairburn, 2008; Wilson, 2005). CBT-E’s method is trans-diagnostic, which means that while a counselor may be aware of his/her client’s bulimia, he/she is also aware that research demonstrates that women are frequently shifting diagnoses across the eating-disorder spectrum (Goss et al., 2010; Fairburn, 2008).
CBT-E for bulimia is designed to repair bulimia by assembling a “formulation,” which is a set of personalized-hypotheses about the unique processes that maintain a woman’s eating disorder (Fairburn, 2008). Then, client and counselor intentionally target said processes in a treatment setting (Fairburn, 2008). The client attends 20 sessions in the course of 20 weeks and the sessions are split into 4 distinct stages (Fairburn, 2008).
Within stage one, the counselor assesses the client’s symptomology, provides psycho-education and creates a unique “trans-diagnostic formulation” that portrays the client’s problematic functioning (Fairburn, 2008). Two essential procedures that clients engage in during phase one are “in-session weighing” and “regular eating,” (Fairburn, 2008). Willingness to examine what weight means and willingness to eat regular meals without maladaptive behaviors or compensatory measures establishes the foundation upon which further change is made (Fairburn, 2008). In stage two, client and therapist take two weekly appointments to reflect on changes made in stage one; they identify obstacles to confront and modify the current formulation (Fairburn, 2008). In stage three there are eight weekly appointments where the client focuses on working through aspects that maintain her bulimic behavior (Fairburn, 2008). Stage four comprises of three appointments that occur every other week; this is the final stage and focuses on preparing the client for coping with a future without bulimia (Fairburn, 2008).
Described above is CBT-E’s default model to treat bulimia (Fairburn, 2008). Fairburn et al. (2008) indicate another broad option, which involves therapeutic interventions surrounding problems central to eating disorder recovery, such as clinical perfectionism, core low self-esteem, mood intolerance and interpersonal problems (Fairburn, 2008). Another model that addresses these etiological and maintaining issues is called Compassion Focused Therapy for Eating Disorders (CFT-E) (Goss et al., 2010). CFT-E for bulimia attends to how affect dysregulation, shame, pride, self-directed hostility and lack of self-compassion perpetuate binge-purge cycles (Goss et al., 2010). Goss et al. (2010) explain that CFT-E is another trans-diagnostic modality that grew off of the CBT foundation. He states that the main difference lies in that CFT-E rigorously encourages intentional self-compassion and makes sure that the CFT-E client “feels” that therapeutic interventions are encouraging and beneficial whereas basic CBT-E is more cerebral.
CBT is consistently a foundation from which further therapeutic interventions blossom. In 2007, Mitchell et al. studied the effects of treatment by means of manualizing CBT, thereby creating a guided self-help and stepped-care treatment for bulimia. These treatments are to be implemented using an “adaptive treatment strategy,” which means that the treatment strategy may be altered at any time based on the shifting clinical condition of the patient (Mitchell, Agras, Crow, Halami, Fairburn, Bryson & Kraemer, 2011). This treatment modality adopts the empirically effective CBT-model but advocates for a less intensive and more cost-effective treatment interventions for bulimia nervosa (Mitchell et al., 2011).
Interpersonal Therapy (IPT)
Interpersonal Therapy (IPT) is the only therapeutic modality for bulimia nervosa that offers results comparable to CBT (Mitchell et al., 2007). It maintains that processing interpersonal factors has healing power because some women engage in bulimic behavior to cope with relational problems (Choate, 2010; Mitchell et al., 2007). IPT for bulimia is conducted for 20 sessions and is broken into sections that include psycho-education, conducting a comprehensive interpersonal inventory and practicing adaptive interpersonal skills (Choate, 2010).
IPT does not focus on eating-behaviors; rather, it attends to the interpersonal deficits, life transitions, grief, conflict avoidance, perfectionism and social avoidance that lead to bulimic behavior (Choate, 2010; Mitchell et al., 2007). The IPT therapist catering to the bulimic client will offer the client feedback on problematic styles of interpersonal interaction that trigger a bulimic response so that she can become aware of and change her maladaptive functioning (Mitchell et al., 2007). The therapist will guide the client to modify expectations, offer communication training and help the client explore feelings and facilitate “grief related emotional processing,” (Mitchell et al., 2007).
Dialectical Behavior Therapy
Dialectical Behavior Therapy (DBT) is the most inclusive and empirically authenticated modality for correcting affective disorders (Safer, Telch & Agras, 2001). Since it has become evident that the impulse to eliminate negative affect is an impetus to bulimic behavior, DBT has been adapted to serve the needs of bulimic clients (Kristeller et al., 2006; Safer et al., 2001). Eating disorder-specific DBT therapy runs for 20 sessions at the rate of one session per week (Kristeller et al., 2006).
DBT targets affect management in individual and group settings by training clients in technique-based mindfulness skills, emotional regulation and distress tolerance (Kristeller et al., 2006). Mindfulness training sets the groundwork for emotional regulation and distress tolerance, as the client must be able to practice non-reactive awareness of emotions in the present moment before she can practice regulating distressing emotions (Kristeller et al., 2006). In DBT work, a bulimic client will non-judgmentally witnesses her distressing emotions, as though they were neutral leaves flowing down a river, without reacting to them via impulsive bulimic behavior (Kristeller et al., 2006).
Safer et al. (2001) conducted a clinical trial that displays how DBT treatment for bulimia reduces the impulsive urge to binge as a response to negative affect. After DBT treatment, participants reported feeling effective in their ability to tolerate affect. Important to note is that Safer et al. (2001) noticed a 0% drop out rate in their trial, which is a significant obstacle to recovery and demonstrates a significantly lower percentage than that of other modalities.
Mindfulness-Based Approaches
While some bulimic participants of CBT, IPT and DBT treatment show substantial healing, others do not (Baer et al., 2006). Several pieces of literature assert that adjunctive treatment for bulimia is necessary, they suggest mindfulness meditation and acceptance-based models (Baer et al., 2006, Desole, 2011, Kristeller et al., 2006). Desole (2011) proposes that applying mindfulness-based approaches to the treatment of eating disorders is ideal because eating disorders exemplify a context latent with affect dysregulation, which mindfulness meditation is empirically evidenced to heal (Desole, 2011).
Research about mindfulness and its relevance for reductions in the binge-eating aspect of bulimic behavior is beginning to emerge in current literature (Desole, 2011). The approaches that reflect promising reduction in binge-eating behavior are Mindfulness-Based Cognitive Therapy (MBCT) and Mindfulness-Based Eating Awareness Training (MB-EAT) (Kristeller et al., 2006).
Mindfulness-Based Cognitive Therapy
Mindfulness-Based Cognitive Therapy (MBCT) has been adapted from its original depression-specific model to one that is specific to binge-eating behavior (Kristeller et al., 2006). Acclimating a depression-based theory to serve the bulimic population is practical; research shows that 35%-78% of the bulimic population suffers from co-morbid depression (Bendfelt-Zachrisson, 1992). The rationale for MBCT for bulimic behavior is that cultivating a non-judgmental view of the self and practicing deliberate acceptance of bodily sensations, perceptions, cognitions and emotions separates an individual from her impulsive urge to binge-eat (Kristeller et al., 2006). This view is based on the notion that binge-eating is driven by an effort to eradicate self-awareness (Kristeller et al., 2006).
The MBCT client is encouraged by her therapist to place attention on hunger and fullness cues, to witness the negative affect that triggers a binging urge in a non-judgmental manner, to question the validity of negative thoughts and to replace maladaptive behaviors with adaptive ones in distressing circumstances (Kristeller et al., 2006). Empirical support for MBCT as it applies to the binge-eating component of bulimic behavior is only budding yet still promising (Kristeller et al., 2006; Baer et al., 2005). Baer’s MBCT study (2005) reported a significant 100% cessation of binge-eating behavior and an increase in adaptive mindfulness practice.
Mindfulness-Based Eating Awareness Training (MB-EAT)
Mindfulness-Based Eating Awareness Training (MB-EAT) was created by integrating components of Mindfulness-Based Stress Reduction (MBSR), CBT and guided eating meditations (Kristeller et al., 2006). Kristeller et al. (2006) describe that MB-EAT operates with the understanding that affect dysregulation syndromes, cognitive and behavioral dysregulation and physiological dysregulation underlie pathological eating patterns. Furthermore, all of these contexts must be re-regulated to internalize and maintain healing from bulimic behavior.
MB-EAT encourages clients to learn how to use self-awareness as a tool to self-regulate pathological eating urges (Kristeller et al, 2006). This approach is backed by psychobiological evidence, which states that the “cultivation of self-awareness of relevant internal cues can engage regulatory systems more effectively,” (Kristeller et al., 2011). Employing regulatory tools cultivates introceptive and proprioceptive awareness, which can help a person discern physiological hunger from “non-nutritive” eating urges (Kristeller, 2011).
MB-EAT intentionally incorporates mindfulness-meditation in order to facilitate awareness of cognitive, affective, behavioral and physiological dysregulation so that the client can take deliberate notice and re-regulate (Kristeller et al, 2006). Non-judgmental attention to thoughts, urges and emotions that are related to food intake and satiety cues (separated into intake awareness and full-ness awareness) is an essential practice within MB-EAT (Kristeller et al., 2006; Kristeller et al., 2011). MB-EAT also incorporates techniques that require the participant to relate to her body and to her food in a compassionate manner, such as mindful body-work, self-soothing touch and making mindful-food choices (Kristeller, 2006).
Conclusion
Bulimia nervosa is often chronic but research shows that some modalities offer is hope for healing. A counselor treating a woman diagnosed with bulimia nervosa must be mindful of etiological and sustaining factors rooted in her client’s internal and external world. Toxic factors, such as emotional dysregulation and receiving dis-compassionate cultural messages about the female body may cause and perpetuate the condition. Empirical evidence is reflected by three treatment modalities, Cognitive Behavioral Therapy (CBT), Interpersonal Therapy (IPT) and Dialectical Behavior Therapy (DBT). CBT may help a bulimic woman challenge the distorted thinking that perpetuates her disorder. IPT facilitates the healing of interpersonal struggles that may trigger maladaptive coping. DBT encourages mindfulness and teaches emotional regulation so to challenge the emotional dysregulation that invites bulimic behavior. Phenomological research supports the use of a mindfulness-meditation-based modality as an adjunct to CBT, IPT and DB; Mindfulness-Based Cognitive Therapy (MBCT) and Mindfulness-Based Eating Awareness Training (MB-EAT) are the therapies relevant to the binge-eating aspect of bulimic behavior.
References

Baer, R.A., Fischer, S., Huss, D.B., (2005). Mindfulness and Acceptance in the Treatment of
Disordered Eating. Journal of Rational-Emotive & Cognitive Behavioral Therapy, 23(4), 281-300.

Bendfeldt-Zachrisson, F. (1992). The Causality of Bulimia an Overview and Social Critique.
International Journal of Mental Health, 21(1), 57-82.

Broussard, B.B., (2005). Women’s Experiences of Bulimia Nervosa. Journal of Advanced Nursing, 45(1), 43-50.

Burney, J., Irwin, H.J., (2000). Shame and Guilt In Women With Eating Disorder Symptomology. Journal of Clinical Psychology, 56, 51-61.

Choate, L. (2010). Interpersonal Group Therapy for Women Experiencing Bulimia. The Journal for Specialists in Group Work, 35(4), 349-364.

Desole, L. (2011). Special Issue: Eating Disorders and Mindfulness. Eating Disorders. 19, 1-5.

Fairburn, C.G. (2008). Cognitive Behavioral Therapy and Eating Disorders. New York, NY: Guilford Press.

Goss, K., Allen, S., (2010). Compassion Focused Therapy for Eating Disorders. International Journal of Cognitive Therapy, 3(2), 141-158.

Johnson, C., Connors, M.E., Tobin, D.L., (1987) Symptom Management of Bulimia. Journal of Consulting and Clinical Psychology, 55(5), 668-676.

Kristeller, J.L., Wolever, R.Q., (2011). Mindfulness-Based Eating Awareness Training for Treating Binge Eating Disorder: The Conceptual Foundation. Eating Disorders, 19, 49- 61.

Kristeller, J.L., Baer, R.A., Quillian-Wolever, R. (2006) Mindfulness-Based Approaches to Eating Disorders. In Baer, R.A, Mindfulness-Based Treatment Approaches: Clinicians Guide to Evidence Base and Applications (pp. 75-91). San Diego, CA: Elsevier.

Mitchell, J.E., Agras, S., Crow, S., Halmi, K., Fairburn, C.G., Bryson, S., Kraemer, H. (2011). Stepped Care and Cognitive Behavioral Therapy For Bulimia Nervosa: Randomized Trial. The British Journal of Psychiatry, 198, 391-397.

Mitchell, J.E., Agras, S. and Wonderlich, S. (2007). Treatment of Bulimia Nervosa: Where Are We and Where Are We Going? International Journal of Eaing Disorders, 40, 95-101.

Safer, D.L., Telch, C.F, Agras, S.W (2001). Dialectical Behavior Therapy and Eating Disorders. American Journaly of Psychiatry, 158, 632-634.

Schupak-Neuberg, E., Nemeroff, C.J., (1993). Disturbances in Identity and Self-Regulation in Bulimia Nervosa: Implications for a Metaphorical Perspective of “Body as Self.” International Journal of Eating Disorders, 13(4), 335-347.

Stice, E., Shaw, H.E. (1994) Adverse Effects of the Media Portrayed Thin-Ideal on Women and Linkage to Bulimic Symptomatology. Journal of Social and Clinical Psychology, 13(3), 288-308.

Wilson, G.T., Shafran, R. (2005). Eating Disorders Guidelines From NICE. Lancet, 365, 79-81.

References: Baer, R.A., Fischer, S., Huss, D.B., (2005). Mindfulness and Acceptance in the Treatment of Disordered Eating Bendfeldt-Zachrisson, F. (1992). The Causality of Bulimia an Overview and Social Critique. Broussard, B.B., (2005). Women’s Experiences of Bulimia Nervosa. Journal of Advanced Nursing, 45(1), 43-50. Burney, J., Irwin, H.J., (2000). Shame and Guilt In Women With Eating Disorder Symptomology Choate, L. (2010). Interpersonal Group Therapy for Women Experiencing Bulimia. The Journal for Specialists in Group Work, 35(4), 349-364. Desole, L. (2011). Special Issue: Eating Disorders and Mindfulness. Eating Disorders. 19, 1-5. Fairburn, C.G. (2008). Cognitive Behavioral Therapy and Eating Disorders. New York, NY: Guilford Press. Goss, K., Allen, S., (2010). Compassion Focused Therapy for Eating Disorders. International Journal of Cognitive Therapy, 3(2), 141-158. Johnson, C., Connors, M.E., Tobin, D.L., (1987) Symptom Management of Bulimia. Journal of Consulting and Clinical Psychology, 55(5), 668-676. Kristeller, J.L., Wolever, R.Q., (2011). Mindfulness-Based Eating Awareness Training for Treating Binge Eating Disorder: The Conceptual Foundation Kristeller, J.L., Baer, R.A., Quillian-Wolever, R. (2006) Mindfulness-Based Approaches to Eating Disorders Mitchell, J.E., Agras, S., Crow, S., Halmi, K., Fairburn, C.G., Bryson, S., Kraemer, H. (2011). Stepped Care and Cognitive Behavioral Therapy For Bulimia Nervosa: Randomized Mitchell, J.E., Agras, S. and Wonderlich, S. (2007). Treatment of Bulimia Nervosa: Where Are We and Where Are We Going? International Journal of Eaing Disorders, 40, 95-101. Safer, D.L., Telch, C.F, Agras, S.W (2001). Dialectical Behavior Therapy and Eating Disorders. American Journaly of Psychiatry, 158, 632-634. Schupak-Neuberg, E., Nemeroff, C.J., (1993). Disturbances in Identity and Self-Regulation in Bulimia Nervosa: Implications for a Metaphorical Perspective of “Body as Self.” Stice, E., Shaw, H.E. (1994) Adverse Effects of the Media Portrayed Thin-Ideal on Women and Linkage to Bulimic Symptomatology Wilson, G.T., Shafran, R. (2005). Eating Disorders Guidelines From NICE. Lancet, 365, 79-81.