Thursday, September 12, 2013

Counseling Clients with Eating Disorders: Finding the Right Assessment

Here is the case study scenario used for the purpose of the following assessment evaluation:

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**

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