The document discusses the essentials of comprehensive eating disorder treatment. It covers 8 key topics: 1. Assessment and history-taking form the foundation of treatment. A thorough initial assessment covers chief complaints, medical history, treatment history, and more. 2. Developing a strong case conceptualization is important. This helps the therapist and client understand behaviors and patterns in context. 3. Restricting, bingeing and purging behaviors extend beyond just food to other areas like relationships. 4. The eating disorder is viewed as a protector, not a villain, that has served to help the client survive. 5. Every eating disorder behavior serves a unique function for each individual, and

1. The Essentials of Comprehensive
Eating Disorder Treatment
Castlewood Treatment Center
Preferred Provider Conference
January 25, 2013
Erin McGinty, LPC, NCC, and
Katie Thompson, LPC, NCC

2. No. 1: Assessment and History-Taking
form the Foundation of Treatment

3. No. 1: Assessment and History-Taking as
the Foundation of Treatment
Rules of Thumb:
o Never assume that a question has been asked
before
o Be specific and thorough
o Neutral presence
o Be on the lookout for patterns and
relationships
o Your conceptualization and treatment plan are
only as strong as your assessment

4. Initial Eating Disorder Assessment
o Chief Complaint
o History of Current Illness
o Medical Complications
o Treatment History
o Family History
o Co-Existing Conditions

5. Initial Eating Disorder Assessment:
Chief Complaint
o Client identifies what he/she is seeking
treatment for
o Assessment of motivation and willingness
to change symptoms

6. Initial Eating Disorder Assessment:
History of Current Illness
o Changes in weight and shape
o Restriction
o Fasting
o Skipping meals
o Restriction of overall caloric intake
o Avoidance of foods
o Good vs. bad foods
o Religious or food restrictions
o Food allergies
o Diet pills
o Identify affective, interpersonal, or other triggers

7. Initial Eating Disorder Assessment:
History of Current Illness
o Binge Eating
o Objective versus subjective binge episodes
o Many clients emphasize loss of control and violation of
dietary standards to define a binge, not the volume of
food consumed (Anderson, Lundgren, Shapiro, &
Paulosky, 2004)
o Frequency of episodes
o Identify affective, interpersonal, or other triggers of
binge eating episodes
o Volume of food
o Types of food
o Post-binge consequences

8. Initial Eating Disorder Assessment:
History of Current Illness
o Purging
o Self-induced vomiting
o Laxatives
o Diuretics
o Ipecac
o Enemas
o Insulin abuse for diabetics
o Chewing and spitting
o Rumination
o Frequency
o Identify affective, interpersonal, or other triggers

9. Initial Eating Disorder Assessment:
History of Current Illness
o Exercise
o Frequency
o Type
o Intensity/duration
o Patterns/repetition
o Degree of compulsiveness
o Relationship to food, violation of eating
disorder rules, and weight

10. Initial Eating Disorder Assessment:
History of Current Illness
o Highest and lowest weights
o Experience of puberty and menstruation
o Amenorrhea and relationship to food and
weight patterns
o Ask the client what weight she considers to
be ideal for her
o Ask the client how she sees herself
currently; underweight, of average weight,
or overweight?

11. Initial Eating Disorder Assessment:
Medical Complications
o Physical consequences of the eating
disorder (e.g., osteoporosis, osteopenia)
o Hospitalizations

12. Initial Eating Disorder Assessment:
Treatment History
o When?
o Where?
o For how long?
o What was the outcome?
o What therapies were helpful and unhelpful?
o What were the experiences within the
therapeutic relationships?

13. Initial Eating Disorder Assessment:
Other Important Information
o Co-existing conditions (e.g., anxiety,
depression, mood disorders)
o Physical assessment (History & Physical)
o Family history of mental illness
o Family dynamics and relationships
o Developmental history (e.g., interpersonal
relationships, trauma, neglect, bullying)

14. Assignments Related to Assessment and
History-Taking
o The Timeline Assignment
o Write out what a typical day in your eating
disorder looks like.
o Write about the worst day in your eating
disorder.

15. No. 2: Build a Strong Case
Conceptualization

16. Case Conceptualization
o Transdiagnostic approach (Fairburn)
o Key behaviors, cognitions, and emotions
o Forming a context in which to understand
current behaviors and patterns; important
for both the therapist and client
o Predisposing, precipitating, and
perpetuating factors
o Core beliefs
o Origins

17. Case Conceptualization and
Schema Therapy (Young, 2003)
o Schemas (Young Schema Questionnaire (YSQ-L2) and
Young Parenting Inventory (YPI))
o Links to the presenting problems
o Schema triggers
o Hypothesized temperamental factors
o Developmental origins
o Core memories
o Core cognitive distortions
o Coping behaviors
o Modes
o Effects of schemas on the therapeutic relationship
o Change strategies

18. Assignments Related to
Case Conceptualization
o Write about the messages you received about
emotions such as anger, sadness, guilt, shame,
happiness, and fear growing up. How did you
observe these emotions being expressed in your
family of origin? What beliefs did you develop
about emotions as a result?
o Write out the overt and covert messages you
received from your family around food, weight,
and shape.

19. No. 3: Restricting, Bingeing, and
Purging Extends Beyond Food

20. Restricting, Bingeing, and Purging
Extends Beyond Food
o A person who Restricts, Binges and Purges
food also does so with most of what they
consume
o Relationships, clothing, emotions, thoughts,
information, possessions, needs,
alcohol/drugs, etc.
o Restricting, bingeing, & purging are learned
from interactions in relationships with primary
care givers & significant individuals.
o When a person R, B or P it is a representation
of what they have learned in relationships.

21. Bingeing On More than Food
o Bingeing represents taking in what a person has
restricted, feels they do not deserve or what they will not
give themselves in balance.
o Bingeing will often take place after periods of
deprivation. “I cannot have this, but I need/want it.”
o Objects consumed in bingeing are not enjoyed or
consumed in a mindful manner.
o A client who binges upon food will often also binge
upon a person or a relationship. When they find
someone “safe” they will try to get as much of the person
as they can, fearful of when that person will no longer be
present.

22. Restricting More than Food
o Restriction is a manifestation of self-hate &
deprivation.
o A client who restricts food will often restrict basic
needs: toiletries, sleep, relationships, enjoyment,
undergarments, connection & even electricity .
o Often this has been modeled, taught or learned in
the context of neglect, abuse, trauma or witnessing
another’s deprivation.
o Individuals report feeling “undeserving,” &
unworthy, that restriction allows them to relieve the
distress & anxiety felt when they have needs and
wants. It can be punishment.

23. Purging More than Food
o Shame & self hate often result after a person
consumes what they have restricted or binged.
o Purging allows a release of what they feel they
cannot keep, have, or hold inside.
o A person will purge objects they have purchased,
anger, a person/relationship & information.
o Often a person will report that they felt “out of
control,” or “overwhelmed,” before they purged.
o Discomfort, anxiety & anger are common emotions
associated with the purging of food, emotions,
information or personal items.

24. Assignments Related to the Eating
Disorder as More than Food
o Write a list of everything that you restrict,
binge, and purge. Where did you learn these
behaviors, what was modeled/taught to you?
o Write an extensive list of all of your needs
and your wants. Write about how you
learned about needs and wants. How does it
feel to have needs and wants?
o Write about what you would say instead, if
you could not restrict, binge, or purge.

25. No. 4: The Eating Disorder is a
Protector, not a Villain

26. The Eating Disorder is a Protector,
not a Villain
Approach No. 1 to Eating Disorder: “Ed's
manipulative and controlling style has made
him an abuser, source of desperation, and
villain to people across the globe.” (Jenni
Schaefer)
Pros and cons to using this approach?

27. The Eating Disorder is a Protector,
not a Villain
Approach No. 2 to Eating Disorder: The
eating disorder is protector, and has served
to keep a client safe and- in some instances-
has been absolutely necessary for them to
survive.

28. The Eating Disorder is a Protector,
not a Villain
“When the body is mistreated, neglected, or violated, one
experiences a loss of control over it and need somehow to
get control back. Eating disorders represent a tenuous
feeling of control, which has been achieved through the
body. Controlling the body, and what goes in and out of it,
becomes an adaptive and defensive reaction to past neglect,
abuse, and developmental deficiencies.
Starving, binging, and purging may be used as adaptive
functions for a disordered self. Disordered eating patterns
are, in part, attempts to resist with the body and to define,
establish, or restore a sense of self.” (Costin, 1996).

29. The Eating Disorder is a Protector,
not a Villain
“Compulsion is despair on an emotional level.
Compulsion is the feeling that there is no one home.
We become compulsive to put someone home.
All we ever wanted was love. We didn’t want to become
compulsive about anything. We did it to survive. We
did it to keep from going crazy. Good for us” (Roth,
2001).

30. The Eating Disorder is a Protector,
not a Villain
o Therefore… we show gratitude for the eating
disorder and the ways in which it has served
our clients
o Clients feel understood and this approach
creates less polarization in the therapeutic
relationship

31. Assignments Related to the
Eating Disorder as a Protector
o Have your eating disorder write a letter to
you, explaining all of the ways it has
protected you over time.
o Write a letter in return to your eating
disorder, expressing gratitude for all of the
ways it has protected you.
o Draw five scenes depicting times in which
your eating disorder protected you.

32. No. 5: Every Eating Disorder Behavior
Serves a Function, that Function is
Different for Each Individual, and the
Function Changes Over Time

33. Every Eating Disorder Behavior Serves a
Unique Function
“Rather than experience the loss of control that loving brings,
many of us choose to feel out of control about something
that is within our control; the food we eat—or don’t eat.
I learned to be frightened of my binges in the same way that I
was frightened of my mother…there was no telling when she
would hit me…there was no such thing as being safe.
Which…is exactly how I felt around food...I transferred the
terror that was outside of me—my childhood terror—to a
terror that was inside of me. When we are compulsive
about food, we recreate familiar feelings of being out of
control…but his time the feelings are encompassed by a
tiny—and much safer—radius: the food that goes in our
mouths, the weight that goes on our bodies” (Roth, 2001).

34. Every Eating Disorder Behavior Serves a
Unique Function
o The eating disorder has a “what” & a “why”
o What the person gets out of it
o Why the person continues to engage in the
eating disorder
o The eating disorder says & demonstrates what
a person often cannot directly exhibit or
explain
o The functions are different and multiple
o Functions evolve over time, and are based
upon past & current unmet needs

35. Every Eating Disorder Behavior Serves a
Unique Function
o The function is a way of demonstrating
what the person cannot create or obtain
with normal means
o The client may need control, sense of safety,
familiarity or to recreate a way to make
themselves feel like a perpetrator made
them feel

36. Every Eating Disorder Behavior Serves a
Unique Function
“Early Maladaptive Schemas fight for survival…this is the
result of the human drive for consistency. The schema is
what the individual knows. Although it causes suffering, it
is comfortable and familiar. It feels ‘right.’ People feel drawn
to events that trigger their schemas. This is one reason
schemas are so hard to change. Patients regard schemas as
a priori truths, and thus these schemas influence the
processing of later experiences. They play a major role in
how patients think, feel, act, and relate to others and
paradoxically lead them to inadvertently recreate in their
adult lives the conditions in childhood that were most
harmful to them. Schemas begin in early childhood or
adolescence as reality-based representations of the child’s
environment.” (Young 2003)

37. Functions of the Eating Disorder
o Survival Strategy
o Provides Comfort
o Inability to express internal
distress to others
o Call for Help
o Fear of Responsibility & of
Growing Up
o Manifestation of unresolved
trauma and deprivation
o Having something that is
one’s own and not controlled
by others
o Numbing
o Substitute for
Love/Affection/Attachment
o Rebellion
o Coping Mechanism
o Substitute for
Relationship/Intimacy
o An OCD ritual
o Covers Horrific Memories
o Manifestation of a parent’s
unfinished business
o A need to care for someone
and escape at the same time
o A way to be out of control
privately
o Relief for depression and
distress
o Keeps others away

38. Assignments Related to the Function of
the Eating Disorder
o Write out what you get out of the eating
disorder and why it “works” for you
o Identify the unmet needs related to the
“what” and “why” of the eating disorder
o In your own words, write out what the eating
disorder says/shows for you that is
unspoken

39. No. 6: The Eating Disorder Signifies
Unfinished Business

40. The Eating Disorder Signifies
Unfinished Business
o The eating disorder is a way of playing out what is unresolved
from the past
o The eating disorder is a way of keeping a person from going
out in the world and leaving a problem unsolved and behind
o The eating disorder keeps bringing a person back to and
recreating the painful episodes in which they needed a safe
other to help them process and manage their reality
o Example: “My binge/purge episodes are a recreation of the
beautiful dinners my mother used to serve on china that my
father turned into his militaristic battle grounds. I can still
see my father slamming my brother’s face into his mashed
potatoes over and over.”

41. The Eating Disorder Signifies
Unfinished Business
o The starvation from the Holocaust (legacy burdens)
o The incest from childhood
o The abuse that took place around food, with food
o The deprivation that allowed parents/older
generations to survive depressions and emigrations
(legacy burdens)
o The eating disorder started at the age mother was
sexually abused; mother could no longer connect
with daughter once she reached the age of the abuse
o The rules and chaos from a parent’s birth country

42. No. 7: The Eating Disorder Is the
Primary Relationship

43. The Eating Disorder as the Primary
Relationship
“Food was our love; eating was our way of
being loved. Food was available when our
parents weren’t. Food didn’t get up and walk
away when our fathers did. Food didn’t hurt
us. Food didn’t say no. Food didn’t hit. Food
didn’t get drunk. Food was always there.
Food tasted good. Food was warm when we
were cold and cold when were hot. Food
became the closest thing we knew of love.”
(Roth, 2001).

44. The Eating Disorder as the Primary
Relationship
o The eating disorder often serves as a means of meeting unmet
needs stemming from primary childhood relationships
o Safety, soothing, comfort, security, predictability
o The eating disorder can take on a parental presence
o The eating disorder serves as a “wedge” between the client and
others; the eating disorder is a less threatening, less volatile, less
vulnerable relationship to be in
“The very purpose of compulsion is to protect ourselves from the
pain associated with love” (Roth, 1991).
o The eating disorder provides a sense of “companionship,”
combating feelings of loneliness, inadequacy, and shame

45. Assignments Related to the Eating
Disorder as the Primary Relationship
o Write about how your eating disorder is
your primary relationship.
o Create a collage depicting the following: 1)
What every child needs, 2) What you
received, and 3) What needs your eating
disorder meets.
o Write about how your eating disorder serves
as a “wedge” between you and others.

46. No. 8: The Eating Disorder Mirrors
Other Relationships

47. The Eating Disorder as a Mirror
o The eating disorder will often cycle in a manner that mirrors the
relationship dynamics from the family of origin
o These dynamics are unique to the person, and can ebb and flow
o The person will restrict affection (and food) to mirror the
deprivation in both parental relationships they experienced
o There will be periods of bingeing upon connection (and food)
when it is available, to satiate the fear of not knowing when the
next time for connection will be available
o Purging will follow periods of connection when experiencing
discomfort in being vulnerable, “needy” or emotionally present.
This will often manifest in food as a representation

48. Assignments Related to the Eating Disorder
Mirroring Relationships
o Write about the metaphors for your eating
disorder and how it is similar to the
relationships you have with people; where else
in life do you restrict, binge, or purge?
o Describe the relationship dynamics/patterns
you witnessed growing up in your family. What
were these like to experience? How do you
recreate these dynamics in food, exercise, with
your body and with others? Depict in words and
illustrate.

49. No. 9: The Eating Disorder Mirrors
Attachment Arousal Patterns

50. Parallel Arousal Systems: Attachment
(Crittendon)
Attachment
o Pain
o Fear
o Anger
o Desire for Comfort
o Comfort
o Bored
o Tired
o Sleep
o Depression
Sexual
o Sexual Pain
o Sexualized Terror
o Aggression/Submission
o Romanticism
o Affection
o Satisfaction
o Afterglow
o Sleep
o Numbness

51. Parallel Arousal Systems: Attachment
Attachment
o Pain
o Fear
o Anger
o Desire for Comfort
o Comfort
o Bored
o Tired
o Sleep
o Depression
Food
o Starvation/Stuffing
o Forbidden/Fear Foods
o Anger at Food
o Fantasizing about Food
o Food as Comfort
o Satiation
o Exhaustion after R/B/P
o Hangover/Sleeping
o Numbness

52. No. 10: It’s Not about the Food…
but It Is about the Food

53. It’s Not about the Food…
but It Is about the Food
o The relationship with the food has to be
renegotiated
o Deconstructing the meaning of food
o Therapeutic meals
o Mindful eating
o Exploration of rituals at the table
o Exposure and response prevention therapy

54. Assignments Related to Renegotiating the
Relationship with the Food
o Write about all of your rituals at the table in
exhaustive detail. What is the function of
each? What are the fears around change?
o Write about your fears of allowing yourself
to taste, enjoy, and desire food.

55. Buy 10… Get One Free!
No. 11: Relapse Prevention is Key

56. Relapse Prevention is Key
Essential Principles:
o Relapse prevention is about more than
avoiding relapse; it is about learning how to
live life without the eating disorder
o Every urge signals an unmet need
o Adaptive Coping Responses (ACRs) should
be geared toward meeting the unmet need
o The intensity of the intervention(s) need to
match the intensity of the unmet need

57. Relapse Prevention is Key
o It is necessary to look at the beliefs that keep a
client from using her relapse prevention plan
(e.g., I don’t have needs; I don’t deserve to meet
my needs; Meeting my needs is selfish)
o Abstinence Violation Effect (AVE) is an
important teaching point, especially for certain
types of clients
o Containment, grounding, self-care, and self-
soothing strategies need to be taught

58. Relapse Prevention is Key
o Identify high-risk situations
o Identify warning signs of relapse
o Differentiate between a lapse and a relapse
o Maintaining a balanced lifestyle
o Looking at unhealthy relationships and
building healthy support systems
o Identifying deficiencies in life skills, and life
skill training

59. Assignments Related to
Relapse Prevention and Beyond
o Urge cards
o Behavioral Chain Analysis (BCA)
o Write out your next relapse in exhaustive detail.
o Write about the life skills you possess but feel
insecure about, the life skills you know you do not
have, and the fears around dealing with specific
things that create anxiety within.
o Create a collage of what you wanted to purge when
you purged last night. Include thoughts, feelings, etc.
What other alternatives could you have used to
“purge” these thoughts and feelings?

60. Urge Cards

61. Urge Cards

62. Resources
Anderson, D. A., Lundgren, J. D., Shapiro, J. R., & Paulosky, C. A. (2004).
Assessment of eating disorders: Review and recommendations for clinical
use. Behavior Modification, 28(6), 763-782.
Costin, C. (1996). Body image disturbance in eating disorders and sexual
abuse. In M. F. Schwartz & L. Cohn (Eds.), Sexual abuse and eating
disorders (113). New York, NY: Brunner/Mazel, Inc.
Roth, G. (2001). When food is love. New York, NY: Penguin Group USA, Inc.
Mitchell, J. E. & Peterson, C. B. (Eds.). (2005). Assessment of eating disorders.
New York, NY: The Guilford Press.
Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: A
practitioner’s guide. New York, NY: The Guilford Press.