Mental Health Counseling Responses to Eating-Related Concerns in Young Adult Women: A Prevention and Treatment Continuum
Choate, Laura Hensley, Schwitzer, Alan M., Journal of Mental Health Counseling
Because susceptibility for eating-related concerns exists along a continuum, this manuscript first introduces a framework for intervention that offers a continuum of responses for addressing such concerns in young adult women. The mental health strategies needed range from early identification and interventions for subthreshold problems to more advanced counseling approaches to address emerging and full eating concerns. It next discusses three different types of interventions." (a) preventive approaches for young women at risk," (b) intermediate approaches for women who demonstrate initial symptoms of disordered eating; and (c) psychotherapeutic interventions for women whose symptoms meet diagnostic criteria for eating disorders.
Over the past decade health and mental health professionals have responded increasingly to gender-related mental health concerns (Arnstein, 1995; Carter & Parks, 1996; Choate, 2008), and the high incidence of eating-related difficulties in young adult women is well documented (Schwitzer, Hatfield, Jones, Duggan, Jurgens, & Winninger, 2008; Schwitzer, Rodriguez, Thomas, & Salimi, 2001). Eating disorders are among the 10 leading causes of psychological distress among young adult women (Mathers, Vos, Stevenson, & Begg, 2000). Although boys and men also experience eating-related problems (Ousley, Cordero, & White, 2008), they are far outnumbered by girls and women with such concerns (Hock, 2006; Wittichen & Jacobi, 2005). Further, although eating-related concerns historically have been associated with European and American girls and women, they now appear across ethnic populations (Becker, Franko, Speck, & Herzog, 2003; Cachelin & Striegel-Moore, 2006). Rich and Thomas (2008) recently found few differences in disordered eating among White, African American, and Latina women in college populations.
These findings are not surprising given current cultural standards regarding the importance of extreme thinness and beauty for women. In fact, previous authors agree that essentially all girls and women in the United States are to some extent pressured to achieve these standards (Peck & Lightsey, 2008; Striegel-Moore & Bulik, 2007). Although some are able to resist these pressures, roughly half of all young adult women develop some combination of the negative cognitive and affective symptoms that are characterized as body image dissatisfaction (BID). Women who experience BID often engage in excessive dieting and maladaptive eating practices. A minority of women who experience these initial characteristics later develop symptoms that meet the criteria for a diagnosable DSM-IV-TR eating disorder (American Psychiatric Association, 2000a): anorexia nervosa (AN), bulimia nervosa (BN), or eating disorder not otherwise specified (EDNOS).
Because eating-related concerns, BID symptoms, and diagnosable eating disorders all exist along a continuum (Stice, Killen, Hayward, & Taylor, 1998), the mental health strategies needed range from early identification and interventions for subthreshold problems to advanced counseling approaches that address emerging and fully existing disorders (Schwitzer et al., 2001; Striegel-Moore & Bulik, 2007). It is therefore important that mental health counselors possess the knowledge and skills to work effectively with women across the continuum. According to the mission statement of the American Mental Health Counselors Association (AMHCA), counselors should be highly skilled in both conducting psychoeducational and prevention programs and providing psychotherapy for resolving mental health problems (AMHCA, 2008). This manuscript therefore first introduces a framework for intervention that offers a continuum of responses for addressing eating concerns in young women and then discusses three types of interventions: (a) preventive approaches for young women at risk for BID; (b) intermediate approaches for women who exhibit initial disordered eating symptoms; and (c) psychotherapeutic interventions for women whose symptoms meet diagnostic criteria for eating disorders.
TRIPARTITE INTERVENTION FRAMEWORK
Drum and Lawler (1988) developed a tripartite intervention approach that may be effective for conceptualizing mental health counseling responses to the continuum of eating-related concerns: Preventive interventions are the strategy of choice when, although no current counseling need exists, susceptibility to a disorder is possible or probable. Because such individuals perceive no urgent need for assistance and have little or no motivation for change, prevention relies most heavily on providing information to increase understanding, enhance attitudes, and promote functional behavior while attempting to minimize resistance. Intermediate interventions are implemented when symptoms cause some difficulties and have the potential to grow but do not yet severely impair the individual's daily life. The goal of intermediate responses is to help an individual in self-directed inquiry and effective problem-solving while keeping resistance low. At the end of the continuum, psychotherapeutic interventions are needed to address recurrent issues and "entrenched dysfunctional life patterns" (Drum & Lawler, p.13) such as full-syndrome behavioral problems and diagnosable mental disorders. These are addressed through more intensive, face-to-face treatment that may require a combination of modalities (e.g., individual, group counseling, inpatient hospitalization, and medication). Here we focus on psychotherapeutic interventions for EDNOS because it is by far the most common eating disorder among adolescent girls and young adult women (Schwitzer et al., 2001; Schwitzer et al., 2008; Wilson, Grilo, & Vitousek, 2007; Wonderlich, Joiner, Keel, Williamson, & Crosby, 2007).
Girls and women in their teens and early twenties are at the highest risk of developing BID, a primary precursor of eating disorders (Stice, 2002; StriegelMoore & Bulik, 2007). Sociocultural theories provide the best explanation for this phenomenon, analyzing the powerful influence of current social and cultural forces on women's body image development in Western societies. Girls are taught at an early age that they are valued primarily for their appearance and that they should pursue the societal ideal of beauty (American Psychological Association [APA], 2007). This ideal considers extreme thinness as central to beauty and necessary for women's social success and happiness (Brazelton, Greene, Gynther, & Omell, 1998). As a result, there are heavy pressures on women to achieve an extremely thin, largely unattainable ideal of beauty and to measure their worth by their ability to meet these unrealistic standards (Mussell, Binford, & Fulkerson, 2000). Because the vast majority of women cannot attain this ideal, they experience what has been termed a normative discontent where it is the expectation that they will dislike their bodies (Rodin, Silberstein, & Striegel-Moore, 1984). At these pressures and concerns are normative, potentially all adolescent and young adult women can benefit from preventive interventions.
Mental health counselors can implement prevention programs for broad audiences of young women in a variety of settings: high schools, colleges and universities, community organizations. It might be particularly effective to make presentations to groups of young women known to be at higher risk for eating disorders (e.g., student athletes, sorority members, or women living in residence halls; Schulken, Pinciaro, Sawyer, Jensen, & Hoban, 1997; Skowron & Friedlander, 1994). Incorporating prevention workshops into programs like first-year orientations, sorority meetings, faith-based group meetings, or high school large group guidance activities can enhance attendance and serve as a spring-board for follow-up programs for interested participants. Counselors can design prevention programs that target the promotion of a positive body image and prevent development of eating disorders by focusing on three primary goals: (a) providing psychoeducation; (b) promoting attitudinal change about the importance of weight and shape; and (c) facilitating behavioral changes, such as cutting back on dieting or excessive exercise. In designing their own programs, counselors can draw upon several models of eating disorders prevention, three of which are discussed below. Because the most effective prevention programs are interactive--helping women to apply the concepts to their own experiences (Stice & Hoffman, 2004)--suggestions for enhancing participant involvement are provided.
In designing prevention programs, mental health counselors can draw on components from a social-cognitive model. Counselors can increase participants' awareness of current sociocultural pressures for thinness and help them assess their attitudes regarding the overvaluation of appearance (Keel, 2005; Levine & Piran, 2004; Stice & Hoffman, 2004). For example, participants can discuss current standards of beauty for women and how messages regarding the beauty ideal are conveyed to them by media, family, and peers.
Counselors can also teach participants basic media literacy skills. Media literacy-the ability to identify, evaluate, and resist media messages--helps women learn how to become active consumers rather than passive victims of media influence (Levine & Piran, 2004). Using media literacy skills participants can learn to identify harmful cultural representations and to explore, deconstruct, and resist the message being sent. To practice these skills, presenters can bring in magazine advertisements from women's magazines and help participants critique the ads. The Media Education Foundation (2004) suggests that young women explore such questions as: "Do real women look like these models? What is the real purpose of this advertisement? Will buying this product help me look like this? If I did look like this, would my life really become like the life portrayed in this ad? Does this model really use this product to help her look like this? What are the consequences of these messages for girls and women?' (1)
Mental health counselors can also use components from a health promotion model in prevention programs. To promote healthful eating and exercise habits, programs can provide education about normative physical development (e.g., weight gains that occur across a woman's life cycle), nutrition, and healthy weight control behaviors. It is especially important for counselors to emphasize the negative effects of dieting and its inability to promote lasting weight loss. They can then discuss a nondieting approach to healthful eating that focuses on the body's energy needs (Stice, Presnell, Gau, & Shaw, 2007). Participants can be led to examine their own eating habits and the ways their food intake affects their energy level throughout the day. Further, they can share ideas for incorporating healthful eating and exercise into a busy lifestyle.
Finally, mental health counselors can draw from the empowerment relational model in designing prevention programs. This model promotes the empowerment of women by their adopting a more active role in transforming the current cultural climate for girls and women (Levine & Piran, 2004). For example, counselors can teach participants about the importance of taking a stand against weightism by refusing to tolerate peer teasing, "fat jokes," or other forms of bias against individuals based upon weight. Participants can discuss the narrowly defined standards of beauty in current culture that are based primarily on physical appearance. Counselors can then introduce a broader definition of beauty that also encompasses qualities other than appearance and can encourage participants to identify these qualities in themselves and in others (e.g., empathy, compassion, kindness, wisdom, loyalty).
Participants can also learn about and join in activism projects. For example, they can participate in the National Eating Disorders Association Media Watchdog program, an activity that supports letter-writing campaigns to protest advertisements that perpetuate limiting and gendered stereotypes about women (NEDA, 2008).
These types of prevention programs are effective in helping participants increase awareness and gain knowledge, but there is little evidence that they effect actual behavior change (Stice & Hoffman, 2004). Although prevention is important in raising awareness of negative sociocultural influences in a broad population of girls and women, these programs may not be effective for women who are already experiencing problems with BID and maladaptive eating practices. This group requires a different approach.
Although almost all women are exposed to sociocultural pressures regarding thinness and beauty, some are more vulnerable than others to development of disordered eating symptoms and then eating disorders. According to a metaanalysis of risk factors (Stice, 2002), women most at risk are those who feel heavy pressure to attain thinness, those who internalize the thin ideal as their own standard for measuring self-worth, those who are exposed to family modeling of negative body image and eating disturbances, and those who possess low self-esteem, negative affect, and perfectionism. Lack of social support from parents and peers is also an identified risk factor (Bearman, Presnell, Martinez, & Stice, 2006; Stice).
Mental health counselors should in particular assess these risk factors when clients display such disordered eating symptoms as extreme dieting, excessive exercise, episodic binge eating, and occasional use of compensatory behaviors, such as self-induced vomiting or laxative and diuretic misuse (Fairburn, 1995). These symptoms do not meet the criteria for AN, BN, or EDNOS but do flag the potential for the more severe problems.
Intermediate interventions designed to prevent full-syndrome eating disorders show more positive outcomes than do preventive programs and have demonstrated actual decreases in symptoms (Stice & Hoffman, 2004; StriegelMoore & Bulik, 2007). It is recommended that mental health counselors offer short-term psychoeducational groups for these women. While working with women individually may be necessary, group work has been shown to be effective because social support has positive benefits (Stice, 2002; Stice & Hoffman). A small-group format provides a sense of universality with women who share similar struggles; it enables women to experience altruism through helping other group members; and it allows them to participate in a natural learning laboratory for discovering new ways to enhance social networks (Yalom, 1995).
Even programs conducted in nontraditional formats can incorporate a social support component. For example, Student Bodies (Zabinski, Pung, Wilfley, Eppstein, Winzelberg, Celio, & Taylor, 2001) is an effective computerized program for college women that provides self-help materials and incorporates an electronic bulletin board for support and a forum for discussion of readings and assignments. In recruiting clients for these groups, mental health counselors can solicit referrals from schools, college counseling centers, agencies, or contacts with women who previously attended prevention programs and need additional information and support. The most effective groups are advertised not as eating disorder prevention programs but as body acceptance or weight control groups. Clients recruited in this way may be less defensive and more open to the information provided (Stice & Hoffman, 2004).
Mental health counselors can incorporate specific psychoeducational and cognitive behavioral components into groups of clients experiencing intermediate-level concerns:
Psychoeducation: In a small group format, counselors can incorporate information about the current sociocultural pressures for thinness that women experience. For example, group members can learn how the thin ideal is presented in media images, its historical context, how it has changed over time, and the negative effect of exposure to media images on women's body image. They can also consider how media images are inappropriate standards for self-comparison. They can be reminded that media images are digitally altered so that even the models themselves do not look like these images. Further, they can discuss the futility of attempting to reach these beauty standards when the majority of women are genetically predisposed to be heavier than the images. They learn to recognize that even with much hard work and effort, they will never achieve the standards (Coughlin & Kalodner, 2006; Yamamiya, Cash, Melnyk, Posavac, & Posavac, 2005). If group members can learn to remind themselves of these facts when viewing media images, they put up buffers against their negative effects (Yamamiya et al.).
Members will also benefit from information about healthy weight management. For example, they can be helped to create lifestyle plans for making changes to eating and exercise habits that do not involve dieting (Stice et al., 2007). Group members will also benefit from activities that help them to appreciate and accept their bodies, an area that is often difficult for girls and women who struggle with negative body image and eating-related problems. It is helpful for members to consider the functionality of their bodies by learning to appreciate the body for what it can do, not just how it appears to others (Avalos & Tylka, 2006).
Cognitive behavioral strategies to alter maladaptive attitudes." Mental health counselors can also help group members begin to identify, examine, and challenge their dysfunctional beliefs and attitudes about shape, weight, and the importance of appearance (Franko, 1998; Celio & Winzelberg, 2000; Zabinski et al., 2001). They can use cognitive behavioral exercises that help clients recognize the negative consequences of comparing themselves with unrealistic standards and challenge negative self-talk (see especially the exercises in Cash, 1997).
Dissonance strategies are also useful in helping group members change their beliefs and attitudes about the importance of weight and shape (Stice, 2002; Matusek, Wendt, & Wiseman, 2004; Yamamiya et al., 2005). Developed by Stice, Chase, Stormer, and Appel (2001), dissonance-based strategies are designed to help young women voluntarily take a stand against sociocultural pressures related to thinness and beauty. The approach is based on the premise that when clients who have already internalized the thin ideal choose to take a stand against these pressures, a tension is created that results in cognitive dissonance. To dissipate the tension, clients tend to alter their beliefs away from endorsing the thin ideal. To use dissonance strategies in groups, counselors might consider the following types of activities:
* Ask clients to conduct a counter-attitudinal role play (e.g., "Role play what you might say to a girl who is engaging in fat talk and who is comparing herself to unrealistic beauty standards").
* Ask them to write a persuasive argument that might dissuade a younger girl they care about from accepting the thin ideal as her social comparison standard.
* Ask them to create a body acceptance program for younger girls. What do they feel girls need to hear in order to resist negative cultural messages?
In a small-group format, a combination of social support, psychoeducation, and cognitive behavioral strategies will best meet the needs of young women with intermediate-level concerns.
It is critical that counselors employ preventive and intermediate interventions to address the needs of girls and women at risk for eating disorders and those experiencing BID and emerging concerns. For clients currently confronting full-blown eating disorders, psychotherapeutic counseling interventions are needed.
The DSM-IV-TR provides fully articulated criteria for two primary eating disorders, anorexia and bulimia (APA, 2000a). A diagnosis of anorexia requires that the client refuses to maintain normal body weight (primary feature), maintains less than 85% of expected body weight or misses three consecutive menstrual cycles (minimum severity), and has an intense fear of gaining weight or becoming fat and a disturbance in body image (associated features), with restricting and binging/purging subtypes. A diagnosis of bulimia requires that the individual experience binge eating and compensatory behavior, such as vomiting, laxative use, or overexercise (primary features), with these behaviors occurring at least twice weekly for at least three months (minimum duration), and a self-evaluation that is unduly influenced by body image (associated feature), with purging and nonpurging subtypes.
The DSM-IV-TR also notes that "because of the diversity of clinical presentations [even within a diagnostic class], it is impossible for the diagnostic nomenclature to cover every possible [client] situation" (APA, 2000a, p. 4). Therefore, each diagnostic class includes at least one not otherwise specified (NOS) category. In the case of eating disorders, the NOS category is used when symptoms do not meet the full diagnostic criteria for anorexia or bulimia but clients clearly exhibit disordered eating patterns and experience distress or impairment in their daily lives. For example, the EDNOS diagnosis might be used to describe a situation in which a woman maintains normally expected body weight and menstrual patterns but experiences other symptoms of anorexia, such as severely restrictive dieting, intense fear of gaining weight, and disturbance in body image. In another situation symptoms might revolve around bingeing only, without compensatory symptoms (recognized experimentally as binge-eating disorder; Devlin, Goldfein, & Dobrow, 2003).
Contemporary researchers generally agree that the vast majority of young adult women with diagnosable eating-related concerns are experiencing disorders covered by the EDNOS umbrella (Fairburn & Bohn, 2005; Schwitzer et al., 2008; Shisslak, Crago, & Estes, 1995; Wilson et al., 2007; Wonderlich et al., 2007). Unequivocally, most young women with eating disorders would be overlooked for treatment if counselors were not aware of EDNOS. For example, in a variety of studies of college women, whereas only 6% of female undergraduates were concerned about anorexia and bulimia, 25% to 40% indicated moderate problems, including extreme worry about body image, weight management, and out of control eating (Bishop, Bauer, & Baker, 1998; Douglas, Collins, & Warren, 1997; Kurtzman, Yager, Landverck, Wiesmeier, & Bodurka, 1989; Schwitzer et al., 2001; Tsai, Hoerr, & Song, 1998).
The most common EDNOS syndrome comprises primary symptoms that are a combination of anorexic and bulimic symptoms that do not meet the criteria for either disorder specifically but result in a disturbance in eating or weight management behavior. Women with EDNOS tend to engage in frequent binge eating and high levels of exercise for weight control, but fewer engage in purging (vomiting or laxative use) as required for a bulimia diagnosis or restrictive eating as required for an anorexia diagnosis. The most common symptoms tend to be clinically significant body dissatisfaction and overattention to body image; rumination about eating and weight management; low or unstable selfevaluations; moderate stress or anxiety or moderate depression; and problematic perfectionism. These symptoms impair daily functioning or cause clinically significant cognitive-emotional distress.
Women with EDNOS tend to say, "I don't have an eating disorder but I think about food all the time." They tend to be resistant help-seekers; and often they initially present with adjustment rather than eating concerns, or include eating as one of several presenting problems. They often try multiple helping relationships without committing to treatment (Agras, Brandt, Bulik, Dolan-Sewell, Fairburn, & Halmi, 2004; Fairburn & Bohn, 2005; Grilo, Masheb, & Wilson, 2001; Johnson, Spitzer, & Williams, 2001; Peck & Lightsey, 2008; Schwitzer, Bergholtz, Dore, & Salimi, 1998; Schwitzer et al., 2001; 2008; Wade, Crosby, & Martin, 2006).
In this article we focus exclusively on interventions for EDNOS because that is by far the most common eating disorder among young women. Although treatment may include a combination of modalities (individual and group counseling, inpatient hospitalization, and medication), here we focus narrowly on outpatient mental health counseling models most appropriate for individual EDNOS treatment, including cognitive behavioral therapy (CBT), interpersonal therapy (IPT), and dialectical behavioral therapy (DBT).
INDIVIDUAL TREATMENT APPROACHES
It has been suggested that clients experiencing EDNOS will respond well to an adaptation of CBT that was originally developed for BN (Fairburn, Marcus, & Wilson, 1993; Wilson et al., 2007). CBT has emerged as the dominant model for understanding and treating eating disorders during the past several decades (APA, 2000b; 2006; Wilson et al.). Recent research also indicates the use of IPT or DBT to treat eating disorders, particularly for women who do not respond well to CBT (APA, 2006; Wilson et al.).
Cognitive Behavioral Therapy
CBT is considered the gold standard for treatment of eating disorders because there is the most evidence for its efficacy (APA, 2000b; 2006; Wilson et al., 2007). Clinical trials comparing CBT with other forms of treatment indicate its superiority to other approaches, including medication (APA, 2000b; 2006; National Institute for Clinical Excellence [NICE], 2004; Wilson et al.). Therefore, according to the National Institute for Clinical Excellence (2004) and the American Psychiatric Association Best Practice Guidelines (2006), CBT is recommended as the first line of treatment for eating disorders, particularly BN.
Central to CBT is its model for understanding maintenance of the disordered eating cycle. According to the classic CBT model of Fairburn and colleagues (1993), a girl or woman with low self-esteem becomes aware of sociocultural messages about the beauty ideal of thinness. She interprets these messages as avenues to achieving the happiness and self-worth she seeks. She then internalizes these messages and believes that body shape and weight are the most important determinant of her worth.
This belief system in which she feels worthwhile only if she meets unrealistic cultural standards contributes to severe, chronic dieting in attempts to attain the ideal. Because strict dieting is not sustainable over time, she will feel deprived and eventually experience a loss of control in maintaining her diet, resulting in a binge episode. Binges are generally followed by extreme compensatory behaviors, such as vomiting, overexercise, or laxative abuse. Because the binge episode also causes her to experience a sense of failure, she then resolves to work even harder to reach her weight and shape standards. The cycle is maintained because she will inevitably fail in her efforts to adhere to her strict diet and achieve her ideal weight, and her self-esteem is actually diminished rather than enhanced (Fairburn et al., 1993; Pike, Devlin, & Loeb, 2004; Pike, Loeb, & Vitousek, 1996; Wilson & Pike, 2001).
CBT treatment is therefore explicitly structured with a focus on the present, emphasizing the resolution of eating disorder symptoms themselves before focusing on a change in cognitions (Pike et al., 1996). The use of homework, provision of psychoeducation, and an emphasis on goals are critical to its success. CBT as adapted for EDNOS is designed to (a) enhance motivation for change through cognitive and behavioral procedures; (b) change maladaptive behaviors by replacing dysfunctional dieting or bingeing with a regular and flexible pattern of eating; and (c) change maladaptive cognitions by decreasing concerns with body shape and weight (Wilson et al., 2007).
Motivational strategies. During the first phase of counseling, it is important for mental health counselors to recognize that the client experiencing EDNOS will likely be at the precontemplative stage of change (Prochaska, DiClemente, & Norcross, 1992) in which she has little to no intent to change her attitudes or behaviors. Motivational interviewing strategies are thus deemed most effective in the initial stages of counseling because they are designed for individuals in precontemplation (Miller & Rollnick, 1991).
The goal in working with clients experiencing EDNOS is to create initial ambivalence about the prospect of changing beliefs and behaviors. It is recommended that the counselor use reflection and open-ended questions to fully explore both the client's model of her eating problem and her fears about the prospect of gaining weight and losing control of her eating, weight, or shape. Counselors can help a client compare the costs and benefits of maintaining her symptoms (e.g., binges, excessive exercise) with the costs and benefits of change. For example, she can examine the short- and long-term consequences of persisting with her eating-related attitudes and behaviors. She can explore what she likes about her current behaviors and identify what she wishes she could release (Vitousek, Watson, & Wilson, 1998). As the counselor reflects the client's words about both the pros and cons of change, she will slowly become more open to the idea that changing is in her best interest (Miller & Rollnick, 1991).
Part of the CBT motivational approach is also to provide the client with meaningful psychoeducation about the CBT model for understanding the cycle of disordered eating. As the client becomes more open to considering such information, she will also benefit from information about the physiological effects of starvation on the body and the ineffectiveness of vomiting and laxative abuse in promoting weight loss (Fairburn et al., 1993; Pike et al., 1996).
Behavioral change strategies. Once the client is open to considering change, mental health counselors can begin to target reduction of actual disordered eating behaviors. Regardless of the client's symptoms, the most important component of behavioral change is helping her to establish a normal pattern of eating. Fairburn and colleagues (1993) asserted that this is the most effective component for interrupting the pattern of chaotic, sporadic eating and should be strongly emphasized. Planning and eating three meals a day plus two to three snacks helps the client to learn to eat regularly, reducing feelings of deprivation and hunger, increasing her energy, and reducing her urges for binges. Because this step is quite difficult for most clients, counselors can encourage them to use an experimental approach to help build initial small successes in the right direction (e.g., if the client feels unable to eat her scheduled meal, she can at least try to eat some fruit or yogurt as a step toward her goal of eating a complete dinner; Pike et al., 1996).
The client is also asked to monitor her food intake on a daily log, recording the time, place, food consumed, type (i.e., meal, snack, binge); whether a binge or purge occurred; and the circumstances around the food consumption. By reviewing these daily logs in session, counselor and client can examine themes and common triggers for eating problems. Based on emerging themes, counselors can help clients to formulate strategies for reducing the risk of skipping meals, bingeing, or purging. For example, a client can make a list of high-risk situations and design a plan for coping; create a menu of alternative activities that are incompatible with binges; design strategies for distraction after eating to prevent her urges to vomit or purge; and gradually begin to eliminate forbidden foods (i.e., foods she forbids herself to eat because of their high calorie or fat content). Relapse prevention is also emphasized as she brainstorms plans for "what ifs?" (e.g., "What happens if I do binge? What will I do if I skip a meal? What will I do when I learn I have gained weight?"). She can learn to view any relapse as a potential learning opportunity, maintain a problem-solving attitude, and return as soon as possible to her pattern of regular eating (Fairburn et al., 1993; Wilson, Fairburn, & Agras, 1997).
Cognitive change strategies. Cognitive work can begin once a client's weight and eating patterns have become somewhat normalized. A cognitive focus is futile as long as the client continues to binge, purge, or diet excessively because she is not able to think clearly or see possibilities for change while her body is undernourished (Fairburn et al., 1993). The goal of the cognitive phase is to help the client challenge her assumptions about the importance of weight and shape as standards for her self-worth. Cognitive restructuring helps her identify dysfunctional automatic thoughts (e.g., "Because I have failed at my diet, I am a failure as a person") and challenge them (e.g., "I really don't have any evidence to support this. I am successful in other areas of my life. Maybe my ideal weight really is too low for my body type"). To help lower her perfectionistic standards, she can work toward acceptance of a medically sound weight range rather than a specific number on the scale (Pike et al., 1996).
Through cognitive restructuring she can also develop alternative ways of appreciating that her worth is not based on appearance-related standards. She can recognize that while her goals are valid (e.g., she desires control, mastery, acceptance), the beliefs and behaviors in which she currently invests most of her energy will not help her achieve her desired goals (Wilson et al., 1997). While the basic components of CBT treatment for EDNOS are described in this article, specific details are beyond its scope. See Fairburn and colleagues (1993) for a complete treatment manual, as well as the references mentioned throughout this section. To help clients for whom binge eating is the primary symptom, Fairburn's (1995) self-help guide for eliminating binge eating is highly recommended.
While CBT focuses on motivation and behavioral and cognitive changes, IPT, with its emphasis on interpersonal concerns, also is a valuable approach for treatment of eating disorders, including EDNOS (APA, 2006; Nevonen & Broberg, 2005; Wilson et al., 2007). It is recommended as an alternative treatment to CBT particularly for those who do not respond well to CBT and who have pressing interpersonal issues (APA; NICE, 2004; Wilson et al., 2007). It is particularly relevant for addressing the interpersonal problems common in young women experiencing EDNOS, such as difficulty with conflict, conflict between the needs for independence and for closeness, victimization history, conflicts in relationships with parents, concerns about meeting others' expectations, and deficits in social problem-solving (Schwitzer et al., 2001). A distinctive feature of IPT is that disordered eating symptoms are not the focus of the sessions; instead, counseling is concentrated on identifying and modifying a client's interpersonal difficulties.
While a complete discussion of IPT as applied to EDNOS is beyond the scope of this article, we offer a brief description of the three phases of treatment. In the first phase, client and mental health counselor work to identify problems in one or more of the following four areas: grief (e.g., working through the mourning process); role transitions (e.g., transitioning through life-changing events that cause undue stress); role disputes (e.g., successfully resolving conflicts with any important figure in the client's life); and interpersonal deficits (e.g., developing skills for improving the frequency and quality of social interactions) (Fairburn, 1997). In the second phase, counselor and client select a single interpersonal problem area and together identify central themes and brainstorm options for courses of action to help the client make initial positive changes in her relationships. For example, the counselor might help the client focus on her struggles for autonomy in the context of her relationships with her parents--a common concern in women with EDNOS. In the final phase of treatment the client processes her feelings about termination, consolidates learning, and reviews her progress (Tantleff-Dunn, Gokee-LaRose, & Peterson, 2004). (2)
Dialectical Behavior Therapy
DBT, a form of behavioral therapy originally developed for work with clients with borderline personality disorder (Linehan, 1993), has garnered recent support for its application to the treatment of eating disorders as both a stand-alone treatment and integrated with CBT (Wilson et al., 2007). DBT assumes that disordered eating symptoms such as those found in EDNOS are a client's attempt to regulate strong emotions and to cope with stressors (Telch, Agras, & Linehan, 2000). DBT is comprehensive in its approach and involves several phases of therapy. However, only the skills training for addressing emotional regulation deficits is discussed here because mental health counselors can easily and effectively blend it into their work with clients experiencing EDNOS (Wilson et al.). The four skill areas are mindfulness, emotional regulation, distress tolerance, and interpersonal effectiveness.
Mindfulness refers to a client's ability to become aware of and stay present during the moment-to-moment experiences in life. For example, she can learn to allow herself to experience her emotions without numbing, avoiding, or labeling them. She learns how she might have been avoiding her feelings through disordered eating symptoms like binges and purges. As she becomes more mindful of the present, she learns to understand the ebb and flow of her emotions (McCabe, LaVia, & Marcus, 2004; Telch et al., 2000).
Emotional regulation helps the client begin to recognize the control she has over her emotional responses so that she copes with them other than through disordered eating. She learns that her perception of any situation directly impacts her emotional response to it, so she can reduce emotional reactivity by changing her thoughts about the situation. She also can learn to reduce reactivity and impulsivity by practicing relaxation training, eating regularly, getting physical exercise, getting adequate sleep, and decreasing alcohol and drug use (McCabe et al., 2004).
Distress tolerance skills help clients to endure life's inevitable challenges. By accepting a situation that cannot be changed and not struggling against it, a client can cope with it more effectively. She can learn adaptive self-soothing strategies for managing these situations that do not include dieting or eating (Telch et al., 2000; Wisniewski & Kelly, 2003).
Finally, like IPT, DBT emphasizes interpersonal effectiveness skills. It is assumed that the client's disordered eating is a way to cope with the frustration of not getting her needs met by others. Therefore, strategies for learning assertiveness and open expression of her thoughts and feelings will help her to more effectively communicate her needs (Telch et al., 2000). (3)
In this article, we identified a continuum of the eating-related concerns of young women, ranging from those who experience sociocultural pressures to those who experience BID and other initial eating concerns to those who have diagnosable eating disorders. We then described a tripartite approach to treatment consisting of preventive, intermediate, and psychotherapeutic interventions targeting different points along the continuum. It was beyond the scope of the current article to fully address treatment models for EDNOS beyond individual outpatient counseling approaches; future articles should delineate other models, such as group and family counseling. Likewise, it was beyond the scope of the article to address treatment for AN or BN specifically; future articles also are needed to fill this gap.
Nevertheless, the framework presented has unique strengths. First, it provides a range of responses to eating concerns in young adult women, emphasizing the importance of tailoring mental health counseling responses to individual client needs. It also highlights the importance of prevention and early intervention in order to interrupt a young woman's progression along the continuum of eating problems.
Another strength of the framework is its focus on EDNOS, which is easily overlooked if the counselor is not sufficiently aware of its prevalence and clinical impact. Finally, the framework incorporates current research for providing effective psychotherapeutic interventions for EDNOS, an area not well disseminated among clinicians (Mussell, Crosby, Crow, Knopke, Peterson, Wonderlich, & Mitchell, 2000). Park (2007) described eating disorders as "one of the most troubling behavioral disorders" confronting girls and young women today (p. 158). Mental health counselors can use the approach described in this article to increase their awareness of and their effectiveness when treating the eating-related concerns experienced by young adult female clients.
Agras, W. S., Brandt, H. A., Bulik, C. M., Dolan-Sewell, R., Fairburn, C. G., Halmi, K. A. (2004). Report of the National Institutes of Health Workshop on Overcoming Barriers to Treatment Research in Anorexia Nervosa. International Journal of Eating Disorders, 35, 509-521.
American Mental Health Counselors Association. (2008). Retrieved November 15, 2008, from www.amhca.org/about/
American Psychiatric Association. (2000a). Diagnostic and statistical manual Of mental disorders text revision (4th ed.). Washington, DC: Author.
American Psychiatric Association. (2000b). Practice guidelines for the treatment of patients with eating disorder (revision). American Journal of Psychiatry,, 157, 1-39.
American Psychiatric Association. (2006). Practice guidelines for the treatment of patients with eating disorders (3rd edition). Retrieved November 15, 2008 from http://www.psychiatryonline.com/content.aspx?aid=138866.
American Psychological Association. (2007). Guidelines for psychological practice with girls and women. American Psychologist, 62, 949-979.
Arnstein, R. I. (1995). Mental health on the campus revisited. Journal of American College Health, 43, 243-251.
Avalos, L. C., & Tylka, T. L. (2006). Exploring a model of intuitive eating with college women. Journal of Counseling Psychology, 53, 486-497.
Bearman, S. K., Presnell, K., Martinez, E., & Stice, E. (2006). The skinny on body dissatisfaction: A longitudinal study of adolescent girls and boys. Journal of Youth and Adolescence, 35, 229-241.
Becker, A., Franko, D. L., Speck, A., & Herzog, D. B. (2003). Ethnicity and differential access to care for eating disorder symptoms. International Journal of Eating Disorders, 33, 205-212.
Bishop, J. B., Bauer, K. W., & Baker, E. T. (1998). A survey of counseling needs of male and female college students. Journal of College Student Development, 39. 205-210.
Brazelton, E. W., Greene, K. S., Gynther, M., & O'Mell, J. (1998). Femininity, bulimia, and distress in college women. Psychological Reports, 83, 355-363.
Cachelin, F. M., & Striegel-Moore, R. H. (2006). Help seeking and barriers to treatment in a community sample of Mexican American and European American women with eating disorders. International Journal of Eating Disorders, 39, 154-161.
Carter, R. T., & Parks, E. E. (1996). Womanist identity and mental health. Journal of Counseling & Development. 74, 484-489.
Cash, T. F. (1997). The body image workbook: An 8-step program for learning to like your looks. New York: New Harbinger Publications.
Celio, A. A., & Winzelberg, A. J. (2000). Reducing risk factors for eating disorders : Comparison of an Internet- and a classroom-delivered psychoeducational program. Journal of Consulting and Clinical Psychology, 68, 650.
Center for Media Literacy. (2006). Retrieved November 15, 2008 from http://www.medialit.org
Choate, L. H. (2008). Girls' and women's wellness. Contemporary counseling issues and interventions. Alexandria, VA: American Counseling Association.
Coughlin, J. W., & Kalodner, C. (2006). Media literacy as a prevention intervention for college women at low or high risk for eating disorders. Body Image, 3, 35-41.
Devlin, M. J., Goldfein, J. A., & Dobrow, I. (2003). What is this thing called BED? Current status of binge eating disorder nosology. International Journal of Eating Disorders, 34, S2-S18.
Douglas, K. A., Collins, J. L., Warren, C. (1997). Results from the 1995 National College Health Risk Behavior Survey. Journal of American College Health, 46, 55-66.
Drum, D. J., & Lawler, A. C. (1988). Developmental interventions: Theories, principles, & practice. Columbus, OH: Merrill.
Fairburn, C. G., (1995). Overcoming binge eating. New York: Guilford Press.
Fairburn, C. G. (1997). Interpersonal psychotherapy for bulimia nervosa. In D. M. Garner & P. E. Garfinkel (Eds.), Handbook of treatment for eating disorders (2nd ed., pp. 278-294). New York: Guilford Press.
Fairburn, C. G., & Bohn, K. (2005). Eating disorder NOS (EDNOS): An example of the troublesome "not otherwise specified" (NOS) category in DSM-IV. Behavior Research and Therapy, 43, 691-701.
Fairburn, C. G., Marcus, M. D., & Wilson, G. T. (1993). Cognitive-behavioral therapy for binge eating and bulimia nervosa: A comprehensive treatment manual. In C. G. Fairburn & G. T. Wilson (Eds.), Binge eating nature, assessment, and treatment (pp. 361-404). New York: Guilford Press.
Franko, D. L. (1998). Secondary prevention of eating disorders in college women at risk. Eating Disorders: The Journal of Treatment & Prevention, 6, 29-40.
Grilo, C. M., Masheb, R. M., & Wilson, G. T. (2001). Subtyping binge eating disorder. Journal of Consulting and Clinical Psychology, 69, 1066-1072.
Hoek, H. W. (2006). Incidence, prevalence and mortality of anorexia nervosa and other eating disorders. Current Opinion in Psychiatry, 19, 389-394.
Johnson, J. G., Spitzer, R. L., & Williams, J. B. (2001). Health problems, impairment and illnesses associated with bulimia nervosa and binge eating disorder among primary care and obstetric gynecology patients. Psychological Medicine, 31, 1455-1466.
Keel, P. K. (2005). Eating Disorders (pp. 142-153). Upper Saddle River, N J: Pearson Prentice Hall.
Kilbourne, J. (2000). Still killing us softly III [Videotape]. Northampton, MA: Media Education Foundation (www.mediaed.org).
Kurtzman, F. D., Yager, J., Landverck, J., Wiesmeier, E., & Bodurka, D. C. (1989). Eating disorders among selected female student populations at UCLA. Journal of American Dietician Association, 89, 45-53.
Levine, M. P., & Piran, N. (2004). The role of body image in the prevention of eating disorders. Body Image, 1, 57-70.
Linehan, M. (1993). Skills training manual for treating borderline personality disorder. New York: Guilford Press.
Mathers, C. D., Vos, E. T, Stevenson, C. E., & Begg, S. J. (2000). The Australian Burden of Disease Study: Measuring the loss of health from diseases, injuries, and risk factors. Medical Journal of Australia, 172, 592-596.
Matusek, J. A., Wendt, S. J., & Wiseman, C. V. (2004). Dissonance thin-ideal and didactic healthy behavior eating disorder prevention programs: Results from a controlled trial. International Journal of Eating Disorders, 36, 376-388.
McCabe, E. B., LaVia, M. C., & Marcus, M. D. (2004). Dialectical behavior therapy for eating disorders. In J. K. Thompson (Ed.), Handbook of eating disorders and obesity (pp. 232-244). Hoboken, NJ: John Wiley & Sons, Inc.
Media Education Foundation. (2004). Retrieved March 24, 2004, from http://www.mediaed.org
Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press.
Mussell, M. P., Binford, R. B., & Fulkerson, J. A. (2000). Eating disorders: summary of risk factors, prevention programming, and prevention research. Counseling Psychologist, 28, 764-796.
Mussell, M. P., Crosby, R. D., Crow, S. J., Knopke, A. J., Peterson, C. B., Wonderlich, S. A., & Mitchell, J. E. (2000). Utilization of empirically supported treatments for individuals with eating disorders: A survey of psychologists. International Journal of Eating Disorders, 27, 230-237.
National Eating Disorders Association. (2008). Retrieved March 24, 2008, from http://www.nationaleatingdisorders.org
National Institute for Clinical Excellence. (2004). Eating disorders Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa, and related eating disorders (Clinical guideline No. 9). London: Author. (Available at www.nice.org.uk/guidance/CG9.)
Nevonen, L., & Broberg, A. G. (2005). A comparison of sequenced individual and group psychotherapy for eating disorder not otherwise specified. European Eating Disorders Review, 13, 29-37.
Ousley, L., Cordero, E. D., & White, S. (2008). Eating disorders and body image of undergraduate men. Journal of American College Health, 56, 617-621.
Park, D. C. (2007). Eating disorders: A call to arms. American Psychologist, 62, 158.
Peck, L. D., & Lightsey, O. R., Jr. (2008). The eating disorders continuum, self-esteem, and perfectionism. Journal of Counseling and Development, 86, 184-192.
Pike, K. M., Devlin, M. J., & Loeb, K. L. (2004). Cognitive-behavioral therapy in the treatment of anorexia nervosa, bulimia nervosa, and binge eating disorder. In J. K. Thompson (Ed.), Handbook of eating disorders and obesity (pp. 130-162). Hoboken, NJ: John Wiley & Sons, Inc.
Pike, K. M., Loeb, K., & Vitousek, K. (1996). Cognitive-behavioral therapy for anorexia nervosa and bulimia nervosa. In J. K. Thompson (Ed.), Body image, eating disorders, and obesity: An integrative guide for assessment and treatment (pp. 253-302). Washington, DC: American Psychological Association.
Prochaska, J. O., Diclemente, C. C., & Norcross, J. C. (1992). In search of how people change: Applications to addictive behaviors. American Psychologist, 47, 1102-1114.
Rich, S. S., & Thomas, C. R. (2008). Body Mass Index, disordered eating behavior, and acquisition of health information: Examining ethnicity and weight-related issues in a college population. Journal of American College Health, 56, 623-628.
Rodin, J., Silberstein, L. R., & Striegel-Moore, R. H. (1984). Women and weight: A normative discontent. In T. B. Sonderegger (Ed.), Psychology and gender: Nebraska Symposium on Motivation (pp. 267-307). Lincoln, NB: University of Nebraska Press.
Schulken, E. D., Pinciaro, P. J., Sawyer, R. G., Jensen, J. G., & Hoban, M. T. (1997). Sorority women's body size perceptions and their weight-related attitudes and behaviors. Journal of American College Health, 46, 69-74.
Skowron, E. A., & Friedlander, M. L. (1994). Psychological separation, self-control, and weight preoccupation among elite women athletes. Journal of Counseling & Development, 72, 310-315.
Schwitzer, A. M., Bergholtz, K., Dote, T., & Salimi, L. (1998). Eating disorders among college women: Prevention, education, and treatment responses. Journal of American College Health, 46, 199-207.
Schwitzer, A. M., Hatfield, T., Jones, A. R., Duggan, M. H., Jurgens, J., & Winninger, A. (2008). Confirmation among college women: The eating disorders not otherwise specified diagnostic profile. Journal of American College Health, 56, 607-615.
Schwitzer, A. M., Rodriguez, L. E., Thomas, C., & Salimi, L. (2001). The eating disorders NOS diagnostic profile among college women. Journal of American College Health, 49, 157-166.
Shisslak, C. M., Crago, M., & Estes, L. (1995). The spectrum of eating disturbances. International Journal of Eating Disorders, 18, 209-219.
Stice, E. (2002). Risk and maintenance factors for eating pathology: A meta-analytic review. Psychological Bulletin, 128, 825-848.
Stice, E., Chase, A., Stormer, S., & Appel, A. (2001). A randomized trial of a dissonance-based eating disorder prevention program. International Journal of Eating Disorders, 29, 247-262.
Stice, E., & Hoffman, E. (2004). Eating disorder prevention programs. In J.K. Thompson (Ed.), Handbook of eating disorders and obesity (pp. 33 57). Hoboken, N J: John Wiley & Sons.
Stice, E., Killen, J. D., Hayward, C., & Taylor, C. B. (1998). Support for the continuity hypothesis of bulimic pathology. Journal of Consulting and Clinical Psychology, 66, 787-790.
Stice, E., Presnell, K., Gau, J., & Shaw, H. (2007). Testing mediators of intervention effects in randomized controlled trials: An evaluation of two eating disorder prevention programs. Journal of Consulting and Clinical Psychology, 75, 20-32.
Striegel-Moore, R. H., & Bulik, C. M. (2007). Risk factors for eating disorders. American Psychologist, 62, 181-198.
Tantleff-Dunn, S., Gokee-LaRose, J., & Peterson, R. D. (2004). Interpersonal psychotherapy for the treatment of anorexia nervosa, bulimia nervosa, and binge eating disorder. In J. K. Thompson (Ed.), Handbook of eating disorders and obesity (pp. 163-185). Hoboken, N J: John Wiley & Sons, Inc.
Telch, C. F., Agras, W. S., & Linehan, M. M. (2000). Group dialectical behavior therapy for bingeeating disorder: A preliminary, uncontrolled trial. Behavior Therapy, 31, 569-582.
Tsai, C. Y., Hoerr, S. L., & Song, W. O. (1998). Dieting behavior of Asian college women attending a U. S. university. Journal of American College Health, 46, 163-168.
Vitousek, K., Watson, S., & Wilson, G. T. (1998). Enhancing motivation for change in treatmentresistant eating disorders. Clinical Psychology Review, 18, 391-420.
Wade, T. D., Crosby, R. D., & Martin, N. G. (2006). Use of latent profile analysis to identify eating disorder phenotypes in an adult Australian twin cohort. Archives of General Psychiatry, 63, 1377-1384.
Weissman, M. M., Markowitz, J. C., & Klerman, G. L. (2000). Comprehensive guide to interpersonal psychotherapy. New York: Basic Books.
Wilson, G. T., Fairbum, C. G., & Agras, W. S. (1997). Cognitive-behavioral therapy for bulimia nervosa. In D. M. Garner, & P. E. Garfinkel (Eds.), Handbook of treatment for eating disorders. 2nd edition (pp. 67-93). New York: Guilford Press.
Wilson, G. T., Grilo, C. M., & Vitousek, K. M. (2007). Psychological treatment of eating disorders. American Psychologist, 62, 199-216.
Wilson, G. T., & Pike, K. M. (2001). Eating disorders. In D. H. Barlow (Ed.), Clinical handbook of psychological disorders." A step-by-step treatment manual (pp. 332-375). New York: Guilford Press.
Wittichen, H. U., & Jacobi, F. (2005). Size and burden of mental disorders in Europe A critical review and appraisal of 27 studies. European Neuropsychopharmacology, 15, 357-376.
Wisniewski, L., & Kelly, E. (2003). The application of dialectical behavior therapy to the treatment of eating disorders. Cognitive and Behavioral Practice, 10, 131-138.
Wonderlich, S. A., Joiner, T. E., Jr., Keel, R, Williamson, D. A., & Crosby, R. D. (2007). Eating disorder diagnoses: Empirical approaches to classification. American Psychologist, 62, 167-180.
Yalom, I. D. (1995). The theory and practice of group psychotherapy. New York: Basic Books.
Yamamiya, Y., Cash, T. F., Melnyk, S. E., Posavac, H. D., & Posavac, S. S. (2005). Women's exposure to thin-and-beautiful media images: Body image effects of media-ideal internalization and impact-reduction interventions. Body Image, 2, 74-80.
Zabinski, M. F., Pung, M. A., Wilfley, D. E., Eppstein, D. L., Winzelberg, A. J., Celio, A., & Taylor, C. B. (2001). Reducing risk factors for eating disorders: Targeting at-risk women with a computerized psychoeducational program. International Journal of Eating Disorders, 29, 401-408.
(1) A recommended resource for educating participants about the influence of advertising is the film Still Killing Us Softly III by Jean Kilbourne (2000). For additional prevention and media literacy resources, see the Media Education Foundation (www.mediaed.org); the Center for Media Literacy (www.medialit.org); the National Eating Disorders Association (www.nationaleatingdisorders.org); and Choate (2008).
(2) For additional information about the IPT approach, consult the IPT treatment manual (Weissman, Markowitz, & Klerman, 2000); Fairburn (1997); and Tantleff and colleagues (2004).
(3) For further resources on emotional regulation skill building, see Linehan (1993) for the complete treatment manual.
Laura Hensley Choate is affiliated with Louisiana State University. Alan M. Schwitzer is affiliated with Old Dominion University. Correspondence regarding this article should be addressed to Laura Hensley Choate, Counselor Education, 122 Peabody Hall, Louisiana State University, Baton Rouge, LA 70803. E-mail: firstname.lastname@example.org).
Table 1 Counseling Responses to Eating-Related Concerns Among Young Women Using the Drum & Lawler (1988) (1) Tripartite Intervention Model: Summary. Preventive Intermediate Psychotherapeutic Interventions Interventions Interventions Population Characteristics No current Emerging/ Recurring/entrenched need/possible moderate need concerns susceptibility No sense of Moderately high Defensive/resistant urgency urgency despite distress Low motivation Low/moderate for change motivation Eating Concern Targets Young women in Young women Experiencing diagnosable teens and 20s internalizing disorders thinness ideal High schools, Low self-esteem Primarily Eating Disorder NOS colleges, community groups High risk: Negative affect Body dissatisfaction Sororities, athletes, college women Normal eating Perfectionism Rumination behavior Normal weight Lack of parental Problematic weight management and peer management support Low or unstable self- evaluations Moderate stress or anxiety Moderate depression Clinically significant perfectionism Intervention Goals Provide Facilitate client Address entrenched information to self-inquiry dysfunction increase understanding Enhance attitudes Develop effective Intensive face-to-face problem-solving counseling Promote functional Maintain low Combination of modalities behavior levels of Minimize resistance resistance Recommended Intervention Models Social-cognitive Psychoeducation Cognitive behavioral therapy models Motivational strategies Health promotion Cognitive Behavioral change models behavioral strategies Empowerment strategies Cognitive change strategies relational to Alter Interpersonal therapy models maladaptive Dialectical behavior therapy attitudes Mindfulness Emotional regulation Distress tolerance skills Interpersonal effectiveness (1) Drum, D. J., & Lawler, A. C. (1988). Developmental interventions: Theories, principles, & practice. Columbus, OH: Merrill.…
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Publication information: Article title: Mental Health Counseling Responses to Eating-Related Concerns in Young Adult Women: A Prevention and Treatment Continuum. Contributors: Choate, Laura Hensley - Author, Schwitzer, Alan M. - Author. Journal title: Journal of Mental Health Counseling. Volume: 31. Issue: 2 Publication date: April 2009. Page number: 164+. © 2009 American Mental Health Counselors Association. COPYRIGHT 2009 Gale Group.
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