Treatment plans are usually used by psychologists to set both short- and long-term goals to improve a patient’s psychological and emotional outcomes. This paper aims to explore the case of a 17-year-old Julia, who was diagnosed with depression, to create a comprehensive plan with relevant interventions and objectives. In addition, the evaluation and ethics issues will also be discussed, thus ensuring that the patient’s condition will be continuously stable.
Behaviorally Defined Symptoms
Julia is a female whose behaviors are representative of bulimia nervosa and depression. The mood swings, binge eating, and purging are the key characteristics of her eating disorder (Gorenstein & Comer, 2015). The patient seems to be obsessed with her weight and appearance to the extent that she restricts her food to avoid overweight feelings, which points to her distorted self-perception. The fact that she gained some weight and lost it rapidly, being unable to stop at the appropriate weight, shows that she does not understand that her behaviors are self-damaging. It should be stated that Julia used to practice purging at least three times per week, which made her admit that such behavior is normal. The symptoms, both cognitive and behavioral, include the compensatory mechanisms, binge eating, violated self-perception associated with the unwillingness to maintain normal body weight, as well as the presence of underweight and the inability to recognize it.
Long-Term Goal
For a long-term period, the goal for Julia is to create healthy eating lifestyles, realistic self-perception, and prevention of new bulimia nervosa outbreaks. In general, this goal is closely related to the development of positive behavioral and cognitive patterns regarding the patient’s body and overall appearance. To achieve this, it is important to promote necessary weight gain and healthy nutrition practices, which can be supplemented by a focus on her emotional well-being.
Short-Term Objectives
A range of short-term goals is essential to guide the achievement of the long-term one. First of all, it is important to address the body image issues through conversations about the normal weight concept and the patient’s increased awareness of her appearance. In particular, this objective is likely to reduce binge eating and purging cases by 70 percent since Julia would adjust her self-perceptions. The second objective is learning how to change nutrition habits in the context of social life: due to the fact that she restricts calories and unable to enjoy foods, the psychologist should work on returning some foods and people who were especially attractive to Julia. Upon the completion of this goal, by the end of the treatment, this patient would be aware of how foods affect her body and mood.
The mastering of compulsive behavior management is another goal that should be addressed partially during each of the treatment sessions. Self-control strategies such as meditation and avoiding triggering factors should be explained to Julia so that she can recognize first urges to binge eating and prevent them. In order to accomplish the mentioned objective, it is also useful to increase the calorie intake up to 2500, while meals can be planned in collaboration with a nutritionist. The usage of food journals with all products and visits to restaurants Julia made should be documented by her and reviewed by the psychologist weekly, which can help in adjusting nutrition and behaviors by approximately 30 percent (Mason, Heron, Braitman, & Lewis, 2016). In combination, these objectives would lead to the patient’s recovery from depression and bulimia nervosa and contribute to her restored self-esteem and socialization.
Interventions
Considering the needs of Julia, a cognitive-behavioral theory (CBT), humanistic approach, and attachment theory will be used as the theoretical orientations to accomplish the short-term objectives identified in the previous section of this paper. The CBT places emphasis on short-term operating factors: it does not search for the causes of today’s attack of bulimia in childhood or a year ago but prioritizes emotions by underlining the connection between sessions of bulimia and emotional states. Waller et al. (2014) state that CBT helps to understand what emotions a person experiences and why to learn to cope with them in a different way, without the help of food and bulimia. Compared to the identified orientation, the humanistic theory views a person as initially good, possessing innate potential qualities to recovery based on inherent self-development, self-improvement, and self-actualization (Kilrea & Richer, 2017). Humanistic psychotherapy is beneficial to improve the quality of life, recover from psychological trauma, and cope with addictions. Gander, Sevecke, and Buchheim (2015) offer the attachment theory that is especially effective in adolescents since their relationships with their family and friends largely affect their self-esteem.
The first objective of adequate body image perception and the second goal of redesigning nutrition habits can be employed in terms of CBT. Julia should be asked to identify and write down dysfunctional thoughts and beliefs (for example, “If I get two more pounds, I will look awful”). After that, she may be invited to find the facts supporting these thoughts and search for arguments and facts that cast doubt on the evidence of the dysfunctional beliefs mentioned. A new self-perception will be formed, which can henceforth be guided in Julia’s thinking and behavior. In accordance with the recommendations of the APA, from the very beginning, “prohibited” foods are to be introduced into the diet, which patients learn to eat in moderation (Waller et al., 2014). Thus, the phobia of certain products will be removed as a risk factor. Food rehabilitation should focus on helping the patient to develop a structured nutritional plan to reduce episodes of both dietary restriction and bingeing.
The third objective related to compulsive behavior management can be addressed in consistence with the principles of humanistic and attachment theories. Humanistic psychology may be used not to predict and control human behavior but liberate a person from the fetters of neurotic tension, which has arisen as a result of his or her deviations from norms (Kilrea & Richer, 2017). The attention of Julia to her state and motives would make it possible to avoid self-deception and facilitate the discovery of the concept of the real self. Most importantly, it should be mentioned that a person unfolds in the context of human relations, and disorders cannot be explained by mere private functions, in which interpersonal experience is not taken into account. Therefore, the work of a humanistic psychologist is aimed primarily at creating favorable conditions for the reintegration of the individual in the process of therapeutic meetings.
For many patients having bulimia, it is characteristic to avoid the affection of attachment, in which independence, emotional detachment, and the tendency to replace a lack of emotional warmth with food are typical to a person. In the case of Julia, one may assume that loneliness and insufficient support are expressed in uncontrollable bouts of overeating and purging, with the help of which she tries to comfort and calm. This peculiarity of attachment to eating disorders makes psychotherapy difficult since painful feelings and unpleasant experiences can be investigated only with the support of a psychologist as a sympathetic person with whom therapeutic affection relationships are established. Nevertheless, the attachment theory proposes the creation of the link between the patient and psychologist to learn to create relationships with other people.
Ultimately, a food journal as the fourth objective may be based on humanistic and CBT theoretical orientations. Julia and her psychologist can start with studying the diary of nutrition and eating behavior for the week, which should also note cases of overeating and purging. Each such case becomes the number one priority for discussion and finding the connection between it and what happened within a few minutes or hours before. The feelings that have arisen in that situation and at the time of discussion should clarify exactly what was involved: self-esteem, attitudes, excessive self-criticism, or any other issues. Accordingly, Julia would learn to monitor her eating, associated feelings, and how to cope with the cases of bingeing and failures to control her behaviors and thoughts.
The integration of multiple interventions and theories within this treatment plan can be justified by the combined application of their most pertinent aspects to the specific case of Julia. The evidence shows that treatment programs, including dietary counseling and patient management, are more effective than those that do not contain these elements. The alimentary rehabilitation for bulimia nervosa involves the formation of patterns of regular food intake without overeating. The treatment of eating disorders should be based on a combined approach, and a multidisciplinary team of specialists should be involved in the treatment of patients, including a psychiatrist, holistic practitioner, and nutritionist. The latter is expected to assist with the food diary, the development of healthy nutrition habits, and overall monitoring of the patient’s condition and symptoms. One should also state that psychopharmaceuticals can be applied to the condition of Julia as a supplemental means of controlling her behaviors. Since this paper focuses on the psychological treatment plan, antidepressants are not discussed in detail.
During individual therapeutic sessions, Julia, under the guidance of a therapist, will analyze the occurrence of stress reactions and their consequences. Based on the analysis, effective stress coping strategy is to be developed, both short-term (for example, using relaxation techniques) and long-term (attitudes, mastering certain social skills, systematic planning, et cetera) techniques need to be identified and adopted by the patient. Group psychotherapy is another modality, the peculiarity of which is its effectiveness in overcoming the sense of shame that usually accompanies eating disorders, as well as providing interpersonal feedback and group support. It is shown that the effectiveness of group psychotherapy is higher with concomitant dietary counseling and frequent meetings up to several times a week.
Evaluation
The anticipated outcome of CBT with regard to the psychological state of Julia is the reduction in her deviant behavior and cognition related to eating. Consistent with Poulsen et al. (2014), it is expected that individual and group sessions would allow the patient to understand her self-perception and improve her awareness of body and weight. The proposed effectiveness of CBT is linked to such strong points of Julia as perfectionism and the intention to enhance her views, while the same issues may be regarded as weaknesses in case the patient relies on them in an excessive manner. The role of the psychologist is to build on the patient’s strengths to use them as positive change facilitators (Le Grange, Lock, Agras, Bryson, & Jo, 2015). As for compulsive behavior management, food diaries, and the introduction of “prohibited” foods, they are likely to address anxiety, shame, aggression, bingeing, and purging as the main feelings and actions that led to bulimia nervosa. It is also anticipated that the above interventions would develop healthy nutrition habits and behaviors with the increase of self-esteem.
The current literature demonstrates that all the interventions identified for Julia are effective, which is proved in the course of randomized controlled trials and observational studies (Le Grange et al., 2015; Poulsen et al., 2014). The evaluation of the outcomes will include the consideration of Julia’s health and behavior indicators in the context of her cultural aspects and social environment. Her study at the college, ethnicity, adolescent age, as well as relationships with friends and family, will be taken into account to assess her psychological health. The repeated use of the DSM-5 diagnostic manual will specify any improvements and determine the need to continue, adjust, or stop the treatment for this patient.
Ethics
A consent form should be signed by Julia prior to the treatment and explanations regarding interventions and their anticipated results. To avoid misunderstanding and ethical dilemmas, the psychologist should interact with the patient’s parents since she is currently underage. For example, the dilemma may occur if parents would discover that they were not aware of the need to participate in the family therapy due to being hesitant to do it. The parents should give their permission to all the manipulations that can be conducted with their daughter. The Ethical Principles of Psychologists and Code of Conduct elaborated by the American Psychology-Law Society (AP-LS) can be utilized to resolve ethical conflicts (Haeny, 2014). Also, pro-custody rights for parents who identify as gay can be considered in this case.
The principles of acceptability, responsibility and non-maleficence are based on the idea that, in the process of correcting deviant behavior, it is necessary to use only those methods that contribute to a person’s personal growth, which are ethically and aesthetically justified and cannot cause mental disorders. It is unacceptable to recognize the use of manipulative techniques that are used without the knowledge of the deviant or without full awareness of the essence of the therapeutic process. In addition, the formation of a new irrational and distorting reality of the individual’s thinking in the process of therapy should be considered unacceptable.
Conclusion
To conclude, the key elements in the treatment of anorexia nervosa and depression are the measures to improve the somatic condition, behavioral and cognitive psychotherapy, while pharmacotherapy is in addition to other treatments. For Julia, cognitive-behavioral therapy, attachment theory, and humanistic theory were selected as the theoretical orientations, and the best results in terms of mood and anxiety are expected to be achieved during their integrated implementation. It can be argued that such behaviors as overeating, purging, and internal beliefs characteristic of this eating disorder are best treated with cognitive-behavioral therapy. More pronounced positive dynamics of mood and behaviors can be achieved with the additional inclusion of family and friends in the treatment process.
References
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