The Case of Alicia
Alicia is 25-year-old female referred by her
partner, Sadie. Sadie is concerned that Alicia’s eating pattern is unhealthy. Alicia
insists that there is nothing wrong and is coming to counseling to humor Sadie.
When asked about her weight, Alicia notes that she could still stand to lose a
few pounds. She acknowledges that she likes to have a treat now and then, and
puts on a little weight, but she can cut back on her eating to compensate. She
reports her height as 5 feet, 5 inches and her weight as 120 pounds. Based upon
the way her clothing hangs loosely off her frame, her report of her weight is
likely an overestimate. Sadie is concerned that Alicia is becoming more moody. Alicia
acknowledges that she isn’t very happy with herself.
Abstract
Counselors have a variety of assessment tools at their disposal when
working with clients. However, if mental health professionals fail to consider
the unique factors of each of their clients, such as age, gender, or cultural
background, the results could be null in the way they are applied to the
client. The following paper will address the case of Alicia, who, while
appearing underweight, still desires to lose a few pounds. There are a variety
of issues a counselor needs to address when deciding which assessment tool
would be most useful when assessing Alicia’s case, including both her physical,
as well as psychological needs.
Counseling Clients with Eating Disorders: Finding the
Right Assessment
Mental health
professionals are often called upon to work with a variety of clients, with
issues ranging from marital discord and adjustment disorders, to dealing with
grief from losing a loved one and battling eating disorders. Each presenting
concern is often more than just the surface issue, as there can be underlying
contributing causes that has led the client to seeking assistance from a
counselor.
One of the roles of a
counselor involves choosing the most appropriate assessment tool, which can,
when used correctly, provide a wealth of information about the client, an
insight into how the clients think and how they perceive the current situation.
Assessments consist of tools which allow counselors to collect information in
order to identify, analyze, evaluate, and address any problems or issues that a
client may be experiencing when seeking assistance from a mental health
provider. Assessments can also serve as a useful asset to evaluate the current
methods of coping the client is currently using, and help to illustrate how
more effective and appropriate coping methods can contribute to a more
successful and positive outcome. Working in conjunction with sufficient
education on the part of the counselor or mental health care professional, such
assessments can assist in appraising the situation, issues, and needs of the
client.
When working with
clients, it is important to take certain aspects into consideration, such as
age, presenting concern, underlying issues, willingness to participate in
treatment, and a multicultural sensitivity on the part of the counselor, in
addition to selecting the correct and most appropriate assessment tool to
incorporate into the initial evaluation of the concern, as well as the
development of the therapeutic treatment plan. The aforementioned
considerations will be addressed in respect to the case of Alicia in the
following sections.
The
Case of Alicia
Alicia, who is in her
mid-twenties, appears in counseling due to a recommendation and prodding by her
partner, Sadie, who was concerned about Alicia’s preoccupation with her weight
and eating patterns. Alicia presents willing to entertain the idea of
counseling, if anything, to satisfy her partner’s concerns.
Initial Intake Assessment
Alicia appears to overestimate her current weight, as
she states her weight is 120 pounds, which according to the body mass index
(BMI) would fall within the “normal weight” range, which ranges from a BMI of
18.5 to 24.9 (http://www.nhlbi.nih.gov/guidelines/obesity/BMI/bmicalc.htm).
Alicia’s given measurements places her BMI at 20.0, however, based on her
physical appearance, her weight is more likely to place her in the underweight
category. While there are some limitations of the BMI assessment, such as a
risk of overestimating the percentage of body fat in athletes and others with
considerable muscle mass (http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/risk.htm#limitations),
the BMI allows for a cursory assessment of a possible medical concern tied to
Alicia’s current weight.
Possible Issues Present
There appears to be a
few concerns present with Alicia, as her weight could be a symptom of another,
more psychologically based disorder. By focusing on the physical appearance,
counselors could risk developing “tunnel vision,” thus possibly missing other
contributing factors, such as anxiety, depression, or other underlying issues.
Alicia is in her early adulthood years, in which many mental health disorders
develop, possibly due to the developmental changes which occur during these
years. According to research into the field of eating disorders, most patients consists
of women between 12 and 25 years of age (Fankhauser & Lee, 2009), which
places Alicia at the end range. However, it is important to remember that
Alicia may have been experiencing disordered eating patterns for some time
before coming in for counseling, and as such, should not be discounted as a
possible concern. It would be important to determine if Alicia is experiencing
either an eating disorder, such as anorexia or bulimia, or instead suffering
from a more diverse diagnosis of body dysmorphic disorder, or BDD.
Possible
Assessments
In order to effectively
evaluate clients, it is imperative that counselors are aware of the various
assessments available for them to use when working with clients. Determining
the presence of a disorder can be a challenge, particularly if the client is
not keen on attending counseling in the first place. The awareness of and
effective implementation of certain assessments are two different aspects with
which counselors need to be well versed, as the assessment is only as valuable
as the accurate selection, correct administration, and skilled evaluation of
the results of a knowledgeable counselor or mental health worker.
Screening for Body Dysmorphic Disorder
While eating disorders
and body dysmorphic disorder can occur concurrently, one does not necessarily
guarantee the other. The Screening Instrument for Body Dysmorphic Disorder
(SI-BDDr) is a screening assessment tool which consists of six screening
questions which correspond to the diagnostic criteria found in the diagnostic
and statistical manual of mental disorders (DSM-IV-TR). The SI-BDDr assesses a
variety of criteria, including: (1) a preoccupation with a perceived or
imagined flaw in appearance, and (2) the preoccupation causes clinically
significant distress or impairment in social, occupational, or other areas of
functioning (Dingemans, van Rood, de Groot, & van Furth, 2012). Each of the
items are scored on the basis of a yes/no answer, which includes questions such
as, “are you preoccupied with the idea that your body or a part of your body is
unattractive, ugly, deformed or not beautiful enough?” Among the participants
in a 2012 study, nearly all (96%) of the participants who had an eating
disorder answered that particular question with a “yes,” regardless of the type
of eating disorder present (Dingemans, van Rood, de Groot, & van Furth,
2012). The use of the SI-BDDr as a screening instrument for body dysmorphia
disorder has been shown to have excellent sensitivity and specificity when used
in a general mental health population (Dingemans, van Rood, de Groot, & van
Furth, 2012).
When working with
clients who may have distorted body images or disordered eating habits, there
are often other psychological concerns present. Some of the associated
disorders, such as obsessive compulsive tendencies, social anxiety, depression,
and comorbid eating disorders can often occur with or be mistaken for body
dysmorphic symptoms (Mancuso, Knoesen, & Castle, 2010), thus making it
imperative that effective screening is performed by a qualified counselor or
mental health care professional. The appropriateness of utilizing the SI-BDDr
with Alicia would depend on the answers she provided during the assessment.
While her low weight and possible preoccupation with food may indicate body
dysmorphia, it would be wise to also examine the possible presence of an eating
disorder, as BDD and eating disorders are two different diagnoses, with
different methods of action.
Eating Disorder Inventory-2
While there is not much
known about Alicia’s history as it pertains to her weight concerns, screening
for an eating disorder would be beneficial. Using the Eating Disorder
Inventory-2 (EDI-2) with Alicia may allow useful information to be gained,
which could help to shape therapeutic treatment plans. The EDI-2 consists of 91
items, which consists of three subscales that address the behaviors concerning
eating, weight, and shape, as well as psychological subscales which consists of
items which are relevant to eating disorders, such as ineffectiveness,
perfection, interpersonal distrust, interoceptive awareness, and social
insecurity (Schinke, 1994) and can be completed via self-report in about 20
minutes. The EDI-2 has been shown to be effective in both male and female
clients over the age of 12 years.
The EDI-2 has been
shown to be effective when assessing for the presence of a variety of eating
disorders, including anorexia nervosa (both restricting and
binge-eating/purging types), bulimia nervosa, and eating disorder not otherwise
specified (NOS). Previous research into the validity of the EDI-2 has revealed
that it is an appropriate assessment tool when measuring the presence of eating
disorders, however the results appear to be more reliable when using the
assessment with female clients, as compared to male clients experiencing eating
disorders (Spillane, Boerner, Anderson, & Smith, 2004). Since Alicia is a
female over 12 years of age, the EDI-2 would be an appropriate tool to utilize
when assessing for the presence of a possible eating disorder.
Depending on the
answers provided by Alicia on the assessments mentioned above (the EDI-2 and
SI-BDDr), further screening may be required, such as incorporating the Beck
Depression Inventory, which could help to address any of the underlying psychological
issues that could be contributing or existing concurrently with the disordered
eating habits exhibited by Alicia, as previous research has suggested that
there is a strong association between the two variables of depression and
eating disorders (Troop, Serpell, & Treasure, 2001).
Ethical Use of Assessments
As a professional
within the mental health care field, counselors have an ethical requirement to
abide by a certain set of rules and regulations, which help to protect both the
client and the counselor when conducting a variety of assessments within the
professional domain. Among the core ethical obligations for counselors to
uphold are professional competency, integrity, honesty, confidentiality,
objectivity, public safety, and fairness (Schmeiser, 1995).
Most of the branches of
counseling have a code of ethics, by which members pledge to abide by and
uphold throughout their professional career. According to the American Mental
Health Counselors Association (AMHCA), Principle 4 addresses the utilization of
assessment techniques, including test selection, administration,
interpretation, and test reporting (AMHCA, 2000). Within the test selection
category, counselors who select the use of a combination of tests, such as
proposed for Alicia, counselors must be able to justify the reasoning behind
their choices (AMHCA, 2000, 4.A.2.), which has been sufficiently addressed in
using the possible combination set forth in the current treatment assessment
plan.
Additionally, the American Counseling Association
(ACA) addresses the importance of the ethical use of assessments in the
professional realm, as Section E of the ACA Code of Ethics (2005) contains
information which pertains to the evaluation, assessment, and interpretation of
the results gathered through the use of assessments in a counseling setting.
According to the ACA, assessment instruments are just one of the components of
the counseling process, and that counselors need to be careful when considering
which instrument is used, consulting the validity, reliability, and
appropriateness for the particular client for which it is intended.
When taking into
account the ethical codes set forth by both the AMHCA and the ACA, the
assessments addressed in the current paper, specifically the Screening Instrument
for Body Dysmorphic Disorder and the Eating Disorder Inventory-2 when used to
assess the presence of either body dysmorphia or eating disorders, or while not
addressed in entirety, the possible administration of the Beck Depression
Inventory, all appear to be appropriate and without ethical contradiction when
used correctly with Alicia.
Cultural Considerations
Just as the AMHCA and
the ACA have regulations set forth in their individual codes of ethics
regarding the administration and use of assessment tools, they too have
regulations that address the importance of not only the counselor being
well-versed in a variety of multicultural topics as they pertain to the
counseling setting and therapeutic interventions, counselors are also reminded
to be cautious when selecting assessments, paying regard to any shortcomings or
assessments which may lack appropriate psychometric properties for the
population or demographic of the client (ACA, 2005, E.6.c.). As per the AMHCA
ethical guidelines pertaining to the client specific cultural considerations,
counselors are reminded to select tests and assessments that are appropriate to
the client, with norms, when applicable to the specific assessment, that fit
the client’s demographics, such as age, gender, and race (AMHCA, 2000, 4.A.5.).
Likewise, during the test interpretation phase, counselors are prompted to take
into consideration possible multicultural factors in not only the test
interpretation phase, but also the diagnosis, prognosis, and therapeutic
treatment plan design (AMHCA, 2000, 4.C.5.).
When assessing the
cultural aspects of the tools suggested for administration with Alicia, there
does not appear to be any possible contradictions, as while the Eating Disorder
Inventory-2 has shown to be not as reliable when used with male participants (Spillane,
Boerner, Anderson, & Smith, 2004), Alicia is a female, which would not pose
a problem with the administration of the EDI-2.
Conclusion
While clients may
present with more obvious concerns, such as a below-healthy body weight, as
with Alicia, there may be other contributing causes which can be assessed
through an effective counseling relationship, incorporating the use of
appropriate assessment tools. If a counselor were to treat merely Alicia’s
weigh concerns, ignoring the other aspects, such as her acknowledgement that
she isn’t very happy with herself, the counseling may not be as effective as if
the therapeutic plan approached Alicia’s treatment in a more holistic fashion,
allowing for the existence of possible other contributing factors, such as
anxiety and/or depression. Through pursuing the eating disorder and possible
body dysmorphia issues, a counselor working with Alicia may be able to make
headway in the other realms of Alicia’s life.
The administering of
assessment tools with clients requires counselors be cognizant of both the
ethical and multicultural considerations which may apply and could possibly
create a contraindication with certain assessment tools. However, while some
tools may be designated as inappropriate for certain groups or demographics of
clients, there are usually a number of other assessment tools at a counselor’s
disposal when working with clients, which may be better tailored to work with
certain multicultural concerns.
**References Available Upon Request**
