Judy Jones the Case of Judy Jones:

Judy Jones

The case of Judy Jones: Using cognitive behavioral therapy for anorexics

Anorexia is one of the most difficult of all psychological disorders to treat and has the highest mortality rate of all mental illnesses. The rates of recovery from all eating disorders are alarmingly low: it is estimated that only 50% of ED patients will make a full recovery, 20-30% will continue to present significant subclinical symptoms, 20-30% will remain chronic and 10% will die (Fursland et al. 2012). "Up to 1-5% of women will suffer from a diagnosable ED in their lifetime" (Fursland et al. 2012). The case of Judy Jones is fairly typical: anorexia tends to have an earlier rate of onset than other eating disorders. Judy is female, middle-class and fairly close to her parents (as is evidenced by the referral through her pediatrician, indicating she is receiving regular medical care).

It should be noted that success rates are particularly abysmal for conventional therapies such as psychodynamic therapy and other therapies which probe the past to treat the patient. One of the few methods with a proven track record of treating this deadly disorder is cognitive behavioral therapy (CBT). CBT is present rather than past-focused and centers on changing behaviors and the patient's current thought processes regarding weight. This would be the suggested approach to take with Judy. It is vital that treatment begins as soon as possible, to minimize the risk of medical complications of the disorder, which would compromise both her health and also the psychological component of her treatment, as anorexics with very low weights (with BMIs under 14) typically must have a certain level of weight restored before any type of talk therapy can be effective.

Cognitive behavioral therapy for eating disorders is specifically designed to treat four critical components of such disorders: "perfectionism, core low self-esteem, mood intolerance, and interpersonal difficulties" (Fursland et al. 2012). During the sessions the therapist sets goals for the client. The client may be ambivalent, given that for many anorexics, maintaining a low weight and eating disordered behaviors have become critical components of their perceived self. Clients are told explicitly that treatment is present-focused rather than past-focused. Once goals are established for treatment, clients are then given various 'homework' assignments to achieve long and short-term goals. Session tasks are called homework and include "recording food intake and participating in behavioral experiments, such as trying avoided foods" (Fursland et al. 2012).

These tasks and goals are age-appropriate, and the types of goals articulated for a fourteen-year-old would be different from that of an adult or a child. Examples of goals might include trying forbidden foods or varying the 'rules' of the patient regarding portion size, contexts for meals, or other aspects of the disorder. For a teenager like Judy, for example, a 'challenge' might include going out for pizza with friends (since anorexics often isolate themselves because of their fears of social obligations revolving eating forbidden foods) or eating lunch in the school cafeteria (anorexics often do not like to be seen eating).

The standard duration of CBT for eating disorders is 20 sessions, although this time period may be extended, particularly for anorexics with medical complications. Although the Jones' insurance situation is currently unclear, it should be noted that one of the values of CBT is its relatively short and focused duration, which may be an issue when the amount of psychological care available is limited by the insurance company. Initial CBT sessions usually take place twice weekly, gradually phasing out to once weekly and are fifty minutes each. They typically begin "with the client being weighed, including the plotting of weight on an individualized graph, and the subsequent collaborative setting of an agenda. Homework is then reviewed, and agenda items are covered (including anything the client wants to discuss). The session is summarized at the end, and homework is collaboratively set" (Fursland et al. 2012).

The process of CBT passes through specific phases. During the first phase, the assessment, the therapist talks with the client and determines the intractability of the behavior, beliefs about weight, and sets goals for treatment. Medical risk is also assessed. The client's eating behaviors are discussed and clients may be given various psychological tests and inventories to clarify the best approach. It is unclear from the patient description what Judy's BMI is, or the specifics of her eating behaviors and exercise patterns. All of these are relevant in terms of designing a program of treatment.

The assessment phase also entails eating disorder education: unlike many other approaches, the CBT approach conceptualizes the client as a rational entity, and strives to use education and a realistic perception of his or her body as an important component of the treatment process. "Psychoeducation helps clients understand what is happening, informs them about maintaining processes (e.g., the vicious cycle of restricting, binge eating, and purging), educates them about health risks, and can correct unhelpful myths (e.g., vomiting is effective in removing calories; many individuals with EDs are unaware that purging only removes 30-60% of calories, at most, because absorption begins within seconds of food ingestion)" (Fursland et al. 2012). Even for a young woman like Judy, CBT still views her as an important part of the treatment process. To help motivate the client, the client is asked to identify the behaviors that trouble her most. The therapist can then help the client understand how treatment will alleviate these problems. For example, many anorexics dislike their constant preoccupation with food. Helping clients understand that insufficient calorie intake to maintain life results in these obsessive thoughts is used as a motivation to encourage them to eat meals at regular intervals. Clients are also given self-monitoring tools to assess anxiety and fullness after meals, and chart their progress in these areas. Weighing clients is usually undertaken once a week and clients are discouraged from weighing themselves at home. Weight is monitored for reasons of health and also to encourage a realistic perception of the client's body.