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Case Example

The following case example of Barb illustrates how the phases and techniques of IPT can be used in treatment of BED.

Barb, a 53-year-old cosmetologist, presented for treatment for BED. At the time of the initial intake, she was having 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 shared that her overeating caused her marked distress. Barbs binge eating began at age 15 and had been followed by years of dieting and weight fluctuations. At 231 pounds, Barb was severely overweight and above the 95th percentile of weight for her age. An investigator-based assessment indicated that she had significant eating psychopathology that included an extreme fear of weight gain and great discomfort in allowing herself or others to see her body. Barb had no other Axis I psychopathology but met criteria for obsessive-compulsive personality disorder with a subthreshold diagnosis of self-defeating personality disorder. Barb had never been in therapy before.

Initial Phase

Barb met with her counselor to begin the interpersonal inventory and identify her current interpersonal problems. During this initial meeting, the counselor talked with Barb about her diagnosis and instructed her about how taking an interpersonal approach would lead to the amelioration of her binge eating. The counselor also educated Barb about BED and reassured her that her ED was driving her incremental weight gain and out-of-control eating rather than a lack of motivation on her part. After learning about her current symptoms by discussing a recent episode, Barb's counselor skipped back to her very first time binge eating, using it as a frame through which to move forward chronologically in time. In doing so, Barb and her counselor together began to construct a life chart of relationship difficulties that were involved in the onset and maintenance of her binge eating problems (see Table 14.3). Barb had a history of conflict avoidance and a fear of criticism. At age 15, she began a series of failed relationships that she had attempted to hide or glorify to appear as the perfect daughter and to not disappoint her parents. Accordingly, she binge ate when she was alone and used food to “numb out” to manage the feelings that she kept private. Barb's attempts at secrecy and use of food to disconnect from her feelings continued throughout her subsequent marriage. Although her husband had been cruel and verbally abusive, Barb worked hard to “fool everyone for 18 years” into believing that she had a fulfilling relationship because she did not want anyone to think that she had failed in her marriage.

Since her divorce, Barb had been in a live-in relationship but remained emotionally disconnected from her boyfriend. In the same way, she concealed her ED from him, ate very little when they were together, and continued to binge eat when alone. At work, Barb shared that she put in 14-hour days because she felt uncomfortable saying no to her customers' requests to see her before and after business hours. Given the long periods of time she spent on her feet without breaks to eat or rest, Barb clearly disregarded her needs to an extreme degree. Consequently, she found herself binge eating at night (such on her way home from work) to avoid the conflicted feelings she had about her resentment and frustration regarding her workload. Together, Barb and her counselor examined the link between her binge eating and use of food as a primary coping strategy to manage her negative affect states and avoidance of conflict. Given her history of unfulfilling relationships and an inability to effectively manage her interpersonal relationships, the counselor identified interpersonal deficits as her primary problem area.

Toward the end of the third session, Barb and her counselor began to collaboratively identify treatment goals that would assist her in working on her interpersonal deficits. Three goals were identified that related to both Barb's

Table 14.3. Life Chart for Case Example: Barb

Age

Weight or Eating Problem

Relationships Events and Circumstances

Mood

5

Normal weight

Tonsils are removed.

6

Begins gaining weight

14

Concerns about weight; first binge; prescribed amphetamines to lose weight

Grandfather died.

Feels sad at funeral but does not cry because she thinks it would be a sign of weakness.

15

Sister gets married, borrows money from parents, and files for bankruptcy with her husband.

Perceives parents as being extremely disappointed in sister.

16

Less concern about weight because “Paul's ex-wife was a lot heavier than me” but begins binge eating

Meets Paul, 23, who works at a gas station.

Does not tell parents about Paul given her fathers high- profile job and position in the community.

Comfortable in relationship; fearful of parents' disappointment; worries about their finding out.

18

Binge eating when alone Loses weight

Becomes engaged to Paul.

Tells sisters, but not parents. Paul breaks off the engagement.

Graduates from high school; goes to beauty school.

Abortion

Paul “steals” back the ring (seen on Paul's new girlfriend); throws herself into work as a secretary; is promoted repeatedly.

(Continued)

18

More comfortable about

Meets Dean, who works as

Deans wife pickets her par-

Does not feel guilty about the

weight (“Dean's wife was a lot heavier than me”).

a salesman; Dean says he is separated from his wife, who is pregnant.

ents' house; parents do not make mention of this.

relationship

Binge eating when alone (“Food was my only friend when he was away”); never eats when with him.

Lies to family and friends, telling them that they got married.

Spouse of coworker tells her Dean is cheating on her.

Moves to Chicago with Dean.

Throws Dean out of the house; on his way out, Dean takes her ring from her jewelry box.

Secrecy (wanting to be “perfect & not disappoint my parents”); homesick

27

Binge eating as an outlet

Gets pregnant, marries Bob, an alcoholic, who is “cruel and verbally abusive.”

Lies to mother that she got pregnant after the wedding; birth of first child.

Compliant, scared

28

Heaviest point; 265 pounds

Bob occasionally shoves her.

Birth of second child; “I channeled my energy into my daughters.”

Hateful

32

“Eating a lot.”

Husband hits her; she stands up to husband only once, to ask him to choose between her and alcohol.

Bob no longer drinks but continues being verbally abusive.

Does not tell anyone (“Nobody had a clue that we didn't have a wonderful marriage”).

Continuing Girl Scout troop leader; very active in church

Scared

Emotionally distant (“I made it happy for me”)

(Continued)

39

Has sex with husband approximately 2 times a year.

Husband invests $80,000 of their joint money in real estate; all money lost; begins saving “every penny' sending $10,000 to her sister to open a savings account for her; becomes a workaholic.

Fearful husband will hit her; obedient; proud at holding onto her feelings; derives esteem from keeping her trouble from her children and others.

41

Eating as a way to “hold everything together.”

Sexual relationship with Bob ends. Although she does not express anger, Bob yells at her, saying he can do whatever he wants with his money.

46

260 pounds, blood pressure increasing with increasing weight

Marital therapy with clergy for 3 months.

47

Loses 90 pounds (170 pounds); lowest adult weight

Files for divorce.

50

Meets current boyfriend.

Mother dies.

Funeral is “a lot less stressful [than my grandfathers] because I knew it was OK to cry.”

51

Moves in with current boyfriend.

Feels satisfied with their relationship.

52

Binge eating at night.

Works 14-hour days or longer, not pausing to eat or rest during the day.

53

231 pounds, binges on objectively large amounts of food 3 times a week, binge eating its most frequent ever.

Does not tell any family members she is seeking help.

binge eating and her work to resolve problems with interpersonal deficits. As her first goal, Barb 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. She was told that many people who struggle with binge eating have difficulty identifying and labeling their affective states. Learning to do this would provide her with 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. As another goal, Barb was encouraged to begin sharing her feelings with others (especially her boyfriend, with whom she lived) rather than trying to avoid potential conflict. The counselor discussed with her that years of lying to important people in her life as well as engaging in self-deceit to maintain an image of perfection had led to her inability to communicate effectively or manage conflict. Given her history of failing to convey her feelings, wishes, and needs to others, beginning to share her full range of feelings with her boyfriend, daughters, and coworkers would be especially important for her work on her interpersonal problem area. As a final goal, Barb was instructed to find ways to nurture herself rather than spend all of her energy caring for others. Consistent with her problem area, Barb had established a pattern (common among binge eaters) of excessive caretaking for others in her relationships. Barb was encouraged to take better care of herself to break the vicious cycle of self-denial that she had established in her significant relationships. In addition, focusing on herself in relationships would also teach Barb about more effectively negotiating her interactions. Given the inextricable link between her problem area and binge eating, Barb's counselor explained that the exclusive focus on these goals would lead to the elimination of her binge eating.

Before beginning the intermediate phase, Barb began doing important work on her goal of taking care of herself and sharing more with her boyfriend. She also began thinking about ways in which she might be able to reduce her workload. As a result, Barb shared with her counselor that she was feeling better about herself. Barb's counselor marked with her the end of the initial phase and indicated that the structure of the sessions would change (i.e., she would take on more responsibility to talk about her progress on her goals).

Intermediate Phase

During the second phase of treatment, Barb continued sharing the work she had been doing on her goals in her outside life. Her counselor encouraged her to notice her style of glossing over problems, and Barb continued to receive helpful feedback, both in and out of sessions, about minimizing her feelings. As Barb 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. In fact, discounting her own feelings in general prevented her from experiencing her emotions or dealing with her feelings in more adaptive ways. About halfway through treatment, to review progress and plan for the remainder of treatment, Barb and her counselor reviewed her midtreatment goal reflection (see Table 14.4).

Table 14.4. Midtreatment Goal Reflection for Case Example: Barb

Area 1. Share your feelings with others rather than avoiding conflict. For example, you can practice confronting significant others in your life (e.g., boyfriend, sisters) when you are upset. You can also practice saying no to people, such as your customers at the salon.

1. In what ways have you used treatment to work on this goal?

Ive worked on sharing more with my boyfriend. Once, I confronted him when I thought he overreacted to something I said, and I could get through him being upset with me. I'm also talking more with my sisters. I even told my sister that she hurt my feelings.

2. How has work on this goal been connected to decreasing your problems with binge eating?

Instead of eating when I'm upset, I can sometimes talk to him about my feelings.

3. In your social network, what changes have you noticed as a result of your work on this problem?

My relationships are going a little better with my sisters and my boyfriend.

4. In what ways have you been unable to work on this problem?

I still have a hard time not working a lot of hours and saying no to my customers.

5. What specific plan do you have for continuing to work on this problem over the next 10 weeks?

I'll try to set some boundaries with my customers, and I want to share more with my daughters.

As treatment progressed, Barb had several occasions at work in which she found herself in conflict with others. In session, the counselor used the IPT techniques of clarification, communication analysis, and encouragement of affect to assist Barb in finding ways of negotiating the conflict. After several attempts, Barb was finally able to experience that conflict could be worked through effectively. In addition, Barb began to share more with her sisters, communicate more effectively with coworkers, and set limits with customers by refusing some of their requests. Toward the end of the intermediate phase, Barb was aware of the enormous energy she had spent trying to conceal her problems and was now sharing more with her friends and family. She reported that as a result her relationships were more satisfying, and in fact she and her boyfriend had become engaged.

Termination Phase

At the beginning of the termination phase, the counselor spoke with Barb about the subtle shift in treatment focus for the remaining sessions. Specifically, the counselor told Barb that the session marked the beginning of the final or termination phase of treatment. Even though Barb would still be encouraged to push forward on her treatment goals, the counselor told her that they would be spending some of the remaining session time reviewing and consolidating her progress, formally saying goodbye to one another, and discussing how she could use what she had learned in treatment to manage future interpersonal challenges. Barb used the remaining time during the termination phase to continue taking better care of herself by decreasing her work hours. By the end of treatment, Barb had also begun to have frank discussions with her daughters about their unresolved feelings about his father. In reviewing her progress, Barb was able to acknowledge that over the course of treatment she was able to recognize her feelings and take care of her needs by making more time for herself. Barb also noted that she was able to attend to negative feelings “without feeling as if the world was coming to an end.” She shared that as she began to accomplish these goals, her relationships with others began to get better.

At the end of treatment, Barb had stopped binge eating. At a 1-year follow-up visit, Barb had lost 70 pounds from her initial assessment weight and continued to be binge free.

 
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