As noted earlier, the primary purpose of this course is to provide the mental health clinician with a solid overview of eating disorders – so that the clinician may operate with some skill and knowledge when presented with a client exhibiting signs and symptoms of an eating disorder.

The primary focus will be on four distinct intervention components: 1) identifying the presence of an eating disorder, 2) assessing the type and severity level of the eating disorder, 3) successfully engaging the client (and her/his family) in the treatment process, and 4) referring the client to the appropriate level of services, from referral to individual or family therapy with an eating disorders specialist, up to and including hospitalization in an inpatient eating disorders unit.

Within these four intervention components, there are many skills that should already be in the repertory of every mental health clinician. Every clinician should have a fundamental understanding of how to conduct a thorough psychosocial assessment, for instance, or how to develop a trusting therapeutic relationship with a client. Because this knowledge base is assumed, we will not spend a great deal of time here covering all of the aspects of each of these intervention areas.

(For clinicians who are uncertain of these foundation skills, or who may wish to review them in preparation for applying the principles of this course, offers a thoughtful and well-constructed overview in "The Fundamentals of Counseling and Treatment: Lessons for Beginning and Experienced Mental Health Clinicians")

Regarding these four components of intervention, what is more important for the clinician to know is: 1) the specialized knowledge that may not be deduced or assumed from a more general knowledge base, and 2) the ways in which other, more general skills of good practice must be modified when working with an eating disordered client.

We will begin with the identification aspects of this knowledge, with special emphasis on the signs of eating disorders for which clinicians must be on the lookout.

Identification of the Problem and Signs of Eating Disorders

As in the case of clients with substance abuse problems, clients with eating disorders may be seen as moving through early, middle and late stages of the disorder. Unfortunately, many clients do not appear for any kind of treatment until the eating disorder has moved out of the early stage, which may almost be viewed as a kind of incubation period.

During this early first phase, the client does not present with a full blown disorder. Rather, the person is in a gradual and complex downward spiral that takes him or her from eating problems and body image concerns (that may be mild and may even pass undetected) to a full-blown eating disorder.

Unlike the incubation period that occurs with a physical ailment like the flu or a cold, an eating disordered patient during the first stages does not seem to feel sick, or present with a vague sense of unease or discomfort. In fact, at the beginning of the disease the patient may seem capable, able, efficient and in charge of herself or himself. In fact, the patient may even seem too competent.

Unfortunately, nascent eating disorders often go completely unnoticed. In a culture that itself values thinness, perfectionism and high achievement, the client at the start of their downward cycle may be viewed being in control of their lives in positive ways. They are not. Their risks are not measured and their hazards and perils yet unknown.

Eating Disorders Factoid

5-10% of anorexics die within 10 years of contracting the disease, and 18-20% of anorexics will be dead within 20 years.

Source: South Carolina Department of Mental Health (Citing a study by the National Association of Anorexia Nervosa and Associated Disorders)

It is important for mental health clinicians to know the early signs of eating disorders, when the full blown disease is just beginning, and before it is too late. Detecting early signs of eating disorders may make a huge difference in the prognosis of a patient. Studies show that early intervention yields more benefits than later intervention. (68) Apparently, the longer an eating disorder goes on, the worse prognosis it holds.

An analogy I like to use when talking about early versus late intervention is the following: early intervention may viewed as saving someone from drowning in a raging ocean by stopping him or her when s/he is beginning to walk towards the water or before the water reaches his/her knees versus retrieving someone half-drowned among the high waves (late intervention).

Eating disorders can develop either slowly or quickly and, more often than not, those who suffer from them act secretively, and may actively hide signs and symptoms from caretakers. Therefore, the signs of trouble may not be apparent at first sight. However, there are trails that mental professionals can follow - and help parents follow, too - to help prevent the development of an eating disorder early in its inception.

Teenagers and pre-teens - before developing a full eating disorder – will usually show a pattern of behaviors that may indicate that an eating disorder is beginning to develop. These behaviors may be social, culinary and/or related to family life. Below, you will find a list of these common indicators.

Signs of Risk of Developing an Eating Disorder or Having a Full Blown Eating Disorder

- Excessive interest in fashion magazines and popular magazines such as Seventeen. Purchasing these magazines and reading them often.
- Concern with looks and with weight.
- Any evidence of excessive or extreme dieting.
- Sudden or erratic weight gain or loss.
- A recent disappointment with a girlfriend, boyfriend or at school followed by dieting.
- Teasing followed by dieting or concern with physical appearance.
- Increased time spent in sports to the detriment of other activities.
- Increased effort in perfecting the mastery of school work.
- Decline in academic performance.
- Increased time spent in isolation, at home or at school.
- Increased interest in cooking or collecting recipes.
- Not eating food that has been carefully prepared from a recipe, but instead insisting that others eat it.
- Not eating the food regularly prepared for the family by the person in charge of cooking in the family.
- Turning into a vegetarian, while cutting back on the fat content of foods.
- Inability to sleep.
- Being awake in the middle of the night ‘studying’.
- Visiting pro-anorexia sites on the web.
- Visiting dieting sites on the web.
- Finding over the counter diet pills in the house.
- Spending more time at home and evading outings, and friends
- Noticing a pattern of very limited amounts of foods deemed as acceptable.
- Noticing big quantities of food disappearing.
- Stashing and hiding food.
- Attempts to disguise how much food is eaten at meals.
- Stomach pain at meal times.
- Calorie counting devices, such as books with calorie measurements or pedometers.
- Exercising at odd times of the day or night.
- Constant talk about weight and looks.
- Avoiding any talk of weight and food.
- Using layers of clothes to cover up the body regardless of temperature.
- Not allowing others to see the body.
- Being irritated.
- Sudden changes in personality.

Eating Disorders Factoid

Only 1/3 of people with anorexia in the community receive mental health care.

Source: National Eating Disorders Association (Citing Hoek, H.W., & van Hoeken, D. (2003). Review of the prevalence and incidence of eating disorders. International Journal of Eating Disorders)

A thorough psychosocial assessment with any pre-teen, teenage, or college age child should probably always include the gathering of information in these areas. This is certainly the case where there is any physical or medical evidence of potential eating problems. Whenever there is suspicion of an eating disorder, co-ordination with a client’s primary care physician is useful to gather additional information about the presence of medical signs and symptoms.

However, it must be noted that clients with eating disorders may not always have available or seek out medical care. Their visit to a mental health clinician may be their point of entry into the medical system. Moreover, not every primary care physician will successfully piece together the clues to note the presence of an eating disorder. For this reason, it is important for mental health clinicians to have at least a cursory awareness of what medical signs and symptoms may denote the presence of an eating disorder.

Anorexia and bulimia will have some symptoms that overlap, and others that are different. Obviously, anorexia will present with low body weight as its primary defining characteristic. Other medical symptoms for anorexia may include: amenorrhea (cessation of menstruation), constipation, headaches, fainting, dizziness, fatigue, cold intolerance, dry skin, hair loss, orthostatic hypotension, hypothermia (intolerance of cold), loss of muscle mass and subcutaneous fat, lanugo (strange hair growing on body), hypoglycemia (low blood sugar), and certain kinds of elevated liver enzymes.

Medical symptoms for bulimia may include: Bloating, fullness, lethargy, GERD (gastric reflux), abdominal pain, sore throat (from vomiting), knuckle calluses, dental enamel erosion, salivary gland enlargement, cardiomegaly (toxicity from ipecac, a medicine that causes vomiting), and a variety of metabolic imbalances from vomiting.

As an eating disorder moves to more severe and more chronic stages, the medical symptoms will increase in number and in severity. It will be easier for the mental health clinician to see them and more difficult for the client to hide them. More severe symptoms, of course, mean that more complex care will probably be required.

A mental health professional needs to assess an eating disorder patient fully. In order to perform the assessment, the professional may utilize many tools. Some professionals utilize them all, while some others use only some of the tools in this list to make the assessment.

A) Individual face to face interview
B) Family interview
C) Self-administered questionnaires
D) Testing
E) History of Family Functioning (how has the family of the patient functioned as a family), past and present.
F) Stressors: past and present.
G) Medical History

If there are signs and symptoms that suggest the presence of an eating disorder, a comprehensive assessment done by competent therapists will also need to include:

A) History of body weight
B) History of body dissatisfaction
C) History of dieting
D) History of behaviors intending weight control and the control of physical shape
E) Assessment of patient’s self-perception including, a history of changes in self- perception
F) Assessment of patient’s personality and, a history of psychological functioning. This psychological history needs to include checking for anxiety, depression, suicidal ideation, OCD signs or symptoms, sexual abuse, substance abuse and use of drugs to induce weight loss. It should also include getting familiar with the changes that the eating disorder may have brought on the patient’s basic personality.

Where possible, attempts should be made to gather information from other parties in the client’s life, typically parents or other family members. The client who has begun an active eating disorder may already be engaged in attempts to keep his or her behaviors secret, so other family members may turn out to be more reliable sources of information.

However, family member may have their own reasons for being resistant, such as fear or shame, and may also engage in attempts to downplay or hide the presence of these indicators. It is important to realize that information provided by a resistant family may contain some of the same distortions as information coming directly from the resistant client. Until it is clear that the family is able to provide accurate information, an attitude of healthy skepticism is often warranted concerning the comprehensiveness of the information being given.

Eating Disorders Factoid

Only 6% of people with bulimia receive mental health care.

Source: National Eating Disorders Association (Citing Hoek, H.W. & van Hoeken, D. (2003). Review of the prevalence and incidence of eating disorders. International Journal of Eating Disorders)

A quick word here on process. Because these same family members may become important partners in the client's treatment attempts, great care must be taken during the identification stage not to move forward too forcefully if the family gives clear signals that they are not ready to fully acknowledge the extent of the problem.

Whenever the family has reached the point of acknowledging the problems, the mental health professional may need to be available to provide emotional support and guidance to the parents of the eating disordered patient.

In a manner similar to working with addicted clients, there may be stages of change the client and family need to go through in order to fully engage in treatment. For those clinicians with less familiarity with the concept of stages of change within therapeutic processes, it might be helpful to familiarize yourself with the work of DiClemente and Velasquez (21, 22) in this area. As stated earlier, motivational interviewing is a useful technique for addressing resistance as clients work through these stages of change.
A more detailed look at this subject may also be found in's course, Motivating Substance Abusers through the Stages of Change: A Comprehensive Overview for Mental Health Professionals.

The use of techniques such as motivational interviewing - even at the point of gathering preliminary information - points out the overlap between the different components of intervention. Choices of how forcefully to pursue the gathering of information will affect the capacity to engage the client in the treatment process.

Similarly, when information is being gathered from the client, there may be indications that the patient would be receptive to input and/or education from the clinician in some or all of these areas. The clinician must be ready for this possibility, with sufficient knowledge to provide useful education about eating disorders and the change process. This input and education may begin to set the stage for engaging the client in treatment – and may even start the client on the road to change.

This is the point at which the clinician must be prepared to enter into discussions with the client concerning questions of body ideals and the complex socio-cultural factors that were previously noted. These initial discussions will need to be undertaken carefully until there is a clearer sense of the client's overall emotional landscape. They must also be performed in a careful enough manner that it does not disrupt the development of a therapeutic alliance.

It must always be understood that eating disorders have adaptive functions for the clients who have them. Early in the process, the patient needs to know that the goal of the therapist is to be helpful, not necessarily to strip her or him of his eating disorder in one sitting. If patients believe that the mental health professional wants to rid them of their eating disorder, they may resist and not come back for treatment.

On the other hand, if the patient feels that the clinician is interested in the patient’s experience and pain - instead of in removing the problem – he/she may be more inclined to enter into therapeutic alliance. For this reason, a key goal in terms of establishing a working alliance would be to create the proper context for the patient to feel comfortable. Once this is done, the patient and the therapist can begin to work unraveling the multiple meanings of the eating disordered behaviors, thoughts and feelings.

As mentioned before, many times it is the family of the client who makes the initial contact with the clinician. When working with the family, there is the same need in the early stages of treatment to balance information gathering with creating a therapeutic alliance.

Important decisions also need to be made – based on careful assessment – of how much room the clinician has to provide education and direction to a family early in the process. While some families will welcome information and want to understand the dynamics of an eating disorder, others may only want relief of symptoms and nothing to do with the treatment.

Please note one additional complication during the information gathering process. Because there are serious health problems attendant to eating disorders, the clinician also needs to be gathering as much information as possible concerning the most pressing health issues for which the patient might need attention.

If the family is available and willing to work with the clinician, it may be able to provide more accurate health care information and help facilitate coordination with the client's health care provider for purposes of gathering information and providing needed care.

The skill and care with which the clinician handles this initial dialogue may begin the work of reshaping the client's emotional landscape – even in the course of the first discussions pursuant to gathering evidence of eating concerns. On a larger scale, it will also be an introduction to the therapeutic process itself. The client - and/or the family - will have an opportunity to see whether the therapeutic process is safe and helpful.

When some therapeutic trust has been established, and where the clinician requires somewhat more objective information about whether an eating disorder may be present, it may be helpful to consider the use of a tool specifically designed to determine the presence of an eating disorder. The tools may be as simple as a self-report questionnaire, such as the SCOFF questionnaire, or something slightly more formal, such as the Eating Disorders Examination-Questionnaire (EDEQ).

However, if the patient demonstrates clear and strong resistance to even acknowledging the possibility of an eating disorder, both the timing and process of introducing these kinds of tools must be considered with great care. The need to develop a trusting therapeutic alliance must generally take precedence over depth and speed of information gathering.

Obviously, the mental health professional will be in a different position if she or he is a member of a team in a hospital or at an institute that specializes in working with eating disorders than if he is in a group or solo private practice. In the first instance the mental health professional will have available - for both supportive and information gathering purposes - other team members, such as the psychiatrist, the psychologist, the intake nurse, other nurses in the unit if the patient is hospitalized, as well as the treating medical doctor.

On the other hand, as a solo practitioner, the treating professional would be in charge of all of the information coordination. The solo practitioner would also need to have in place ongoing resources and a referral system. Cases may range from the very mild to the very severe, where medical care might be required and referrals might need to be made very quickly.

Eating Disorders Factoid

Without treatment, up to 20% of people with serious eating disorders die. With treatment, that number falls to 2-3%.

Source: South Carolina Department of Mental Health

Evaluation of the Level of Care Needed

When a client comes to see you with an active eating disorder, one of the important decisions that will need to be made will involve a determination of the appropriate level of care. Typically, there will be a choice of five different levels of care: 1) Outpatient treatment with an eating disorders specialist/group/program; 2) Intensive outpatient treatment, typically with a group or program that specializes in eating disorders; 3) Full-day outpatient treatment; 4) Residential treatment; 5) In-patient hospitalization.

Decisions about level of care will be based upon several considerations. First is the severity of weight loss. If a client weighs in at less than 85% of the normal body weight for their age, height, and body type, then the client is a candidate for outpatient treatment. At less than 80% of normal body weight, intensive outpatient should be considered. At less than 70%, full-day outpatient services are likely needed.

At any point below 85% of normal body weight, residential treatment might be indicated, if motivation for treatment is generally poor, if there are indications of suicidality, or if there is a great deal of pre-occupation with ego-syntonic thoughts of dieting or further weight loss.

When residential care is being considered, and in all instances of a choice of outpatient care, the client must be considered medically stable. Otherwise, referral to a hospital setting is indicated.

Inpatient hospitalization is typically considered for adults when their weight is below 75% of normal, and there are either medical or psychiatric complications - or a risk of suicidal intentions, with a plan - that require round the clock medical care and/or supervision.

For children, inpatient hospitalization is typically used when there is acute weight loss and food refusal on the part of the child. For both children and adults, if there is a refusal to cooperate with treatment, or an extreme pre-occupation with ego-syntonic thoughts of dieting and weight loss, then hospitalization will probably be required. These factors demonstrate very poor motivation for treatment and can be considered very high risk signs and symptoms.

Motivation for treatment is also an important factor that is considered when making decisions about level of care. Regular outpatient treatment should be considered only when the motivation for treatment is considered good to fair. As the level of motivation decreases, then progressively higher levels of care would be indicated.

Finally, when there are other co-morbid factors, such as the presence of obsessive-compulsive disorder, substance abuse, severe anxiety or depression, this may also influence decisions on the appropriate level of care. A co-morbid disorder that itself requires a higher level of care would obviously point in the direction of that higher level of care.

A key fact must be reiterated here. At a certain point in the progression of AN, the client can lose enough weight that he or she moves into starvation mode. At such a point in time, both the body – and, more importantly, the brain - do not have the caloric resources to function normally.

When this point is reached, therapy by itself is going to have a very difficult time producing any useful outcomes. In fact, the client may not be able to make any good decisions about the future direction of his or her life because the decision making areas of the brain may simply not be functioning well enough to allow for good decision making.

For this reason, it is sometimes necessary to delay the use of psychotherapy until medical steps can be taken to bring the client out of starvation mode. Only when the brain is functioning more normally can a clear evaluation be made concerning the client's ability to move through a therapeutic process.

To reach such a point, the treatment team may elect to engage in more directly coercive methods of force feeding the client, either through intravenous or tube feeding. To justify these restrictions to the client's autonomy rights, the treatment team would be viewing the client as no longer being competent to take care of himself or herself, or at imminent risk.

When a clinician is performing an initial assessment of a severely anorexic client who is not engaged in any sort of treatment, the clinician may be placed in the position of having to determine whether the client may require immediate involuntary hospitalization. It is this factor that clarifies why the clinician must have a solid background of information to know how to proceed.

For a clearer visual picture of how these factors work together in determining the proper level of care, you may wish to view the table organized by Sarah D. Pritts, M.D., and Jeffrey Sussman, M.D. at the following link for the American Academy of Family Physicians:

Eating Disorders Factoid

With treatment, about 60% of people with eating disorders recover, and another 20% partially recover.

Source: South Carolina Department of Mental Health

Engaging the Eating Disordered Client in Treatment

As we have already discussed, the process of engaging the client in treatment must begin from the very first point of contact, even as one is still gathering information. One of the important building blocks of this process will consist of exploring and increasing the client's internal motivation for change.

This will not – in all likelihood – be a simple and straightforward process. From the very beginning of this course, we have noted that eating disorders are complex, multi-layered illnesses, with numerous components that factor into the client's emotional landscape in complicated ways. Any of these components may present us with an opportunity to engage the client and increase commitment to positive change.

However, because we do not know which specific components may present us with a "teachable moment" at which particular point in time, we must have some degree of preparation to handle them all. The information presented to this point in the course has been in preparation for understanding the "what" of this process. In this section, we will also try to provide some information about the "how" of this process.

We will, however, try to operate with a manageable amount of information. For an organizing structure, we will use the Signs of Risk we presented earlier in this section. Some of the material in this section will include a little more explanation of why these factors represent some elements of risk, covering the underlying issues and complications.

We will also spend some time examining some possible methods of shaping the discussion about that risk factor with the client. This will include some actual dialogue that may be used by a clinician in discussions with an eating disordered client.

Some of the information shown below would be more likely to be incorporated into the longer term work performed by a specialist in eating disorders, as part of the ongoing therapy. However, as stated earlier, clinicians cannot predict when there will be opening for a “teachable moment.”

The successful use of the teachable moments may make the difference between a client engaging in treatment or dropping out of treatment. This is one reason that we will include this more comprehensive presentation of material.

There is another reason we will address some of these signs and symptoms from the perspective of how a specialist will handle them in treatment. Once the problems have been identified, the client assessed, and some degree of engagement in treatment has been developed, the client will need to be referred to an appropriate specialist in eating disorders.

It is very helpful for the referring clinician to have at least some understanding of the treatment issues, and the corresponding approaches that are likely to be utilized by the eating disorders specialist. This allows the referring clinician to have some ability to prepare the client for treatment and answer some of the client’s questions about what treatment is likely to entail.

For similar reasons, a later section will follow that provides a substantial amount of information about the models of treatment used by eating disorders programs and specialist.

Eating Disorders Factoid

About 80% of girls/women who have accessed mental health services do not get the intensity of treatment they need to stay in recovery.

Source: South Carolina Department of Mental Health