Case Study
Patient Demographic: Name: Tina Clinical Issues: Maladaptive eating behaviors Diagnostic Category: Feeding and Eating Disorders Provisional Diagnosis: F50.01 Anorexia Nervosa, Restricting Type Age: 21 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Italian American Marital Status: Not Married Modality: Individual Therapy Location of Therapy : University counseling center  
Mental Status Exam: The client presented with a slender physique and was observed wearing conservative, dark-colored attire. Her overall demeanor was reserved, displaying noticeable nervousness and a tendency to withdraw from interactions. Upon conversing with her, it became evident that her train of thought often deviated from the topic at hand, hinting at a tangential pattern. This difficulty in maintaining concentration appears to be a consequence of her heightened anxiety levels. Delving deeper into her thought content, a recurring theme of obsessions surrounding food and body weight emerged. Additionally, a palpable fear of judgment from her peers and the broader society was evident. In terms of her cognitive functioning, she was found to be alert and fully oriented to her personal details, as well as her current location and time. However, a significant concern is her limited insight into her present circumstances and the implications of her behaviors. Throughout the assessment, there were no indications of any memory impairments.
Presenting Problem: First session You are a mental health therapist working in a university counseling center. The client, a 21-year-old female, presents issues related to anxiety, poor body image, and eating. You begin the session by introducing yourself and explaining your role as a therapist. You also explain how confidentiality is handled and make sure that she understands her rights as a client. After the initial introductions, you ask her to tell you about her current situation and what led her to seek out therapy. She reports that she has been feeling anxious for a while, but it has gotten worse since a basketball game when someone in the audience yelled to the referee "thunder thighs over there needs to get her act together!" Even though the comment was not directed at her, she internalized it. She explains that she was already feeling uneasy due to her stepfather's comments about her weight from a few years ago, and the recent insult at the game made it "all come crashing down" for her. Now, she cannot stop ruminating about her appearance. She saw a poster in her dorm room promoting counseling services and decided to make an appointment.    You continue your interview by asking about her current eating behaviors. She explains that she avoids carbohydrates, sugar, and most dairy "since that stuff makes you fat." When you ask her to describe what she eats during a typical day, she says, "I usually have a fruit smoothie with almond milk for breakfast, an apple and 12 nuts for lunch, and then some steamed vegetables or a salad for dinner." When asked about exercise or other physical activity besides basketball, she reports that she runs at least seven miles on a nearby trail every morning and spends two hours swimming laps at the indoor gymnasium pool every evening before bed. She says, "The pool is pretty quiet at night. I don't like to be around a lot of people when I'm exercising."    As you continue your dialogue, you ask the client open-ended questions to explore her relationship with her parents, especially her stepfather. She reports that her stepfather has always had negative remarks about her size and shape. She states that she feels like he views her as "less-than" because of her weight, which has led to feelings of shame and worthlessness. You explore the dynamic further by inquiring about how these comments have impacted her self-esteem. She reports feeling anxious, embarrassed, and inadequate when her stepfather is critical. You validate her feelings and explain that comments like these can be very damaging to a person's self-image.    You ask the client what she hopes to accomplish in therapy. After some thought, the client says that she wants to learn how to manage her anxiety. She looks at your shyly and says, "I also want to be able to eat a piece of chocolate. I know that sounds crazy, but I just want to be able to enjoy it, without feeling guilty or like I'm going to get fat." You affirm her desires and explain that a key part of the therapeutic process will be to help her build self-confidence and develop healthier relationships with food.  Sixth session You have been working with the client in intensive outpatient therapy and have been meeting with her two times per week. She is under medical care at the university's health center and has started taking an anti-anxiety medication that was prescribed by her physician. You have also referred her to a nutritionist for specialized guidance on developing a healthier relationship with food. You have established a strong, trusting relationship, and she has told you that she feels comfortable talking to you.    Today, the client brings up an issue that has been bothering her for a while: anxiety about eating around other people. She tells you that she usually gets her food "to go" from the cafeteria and eats at a bench outside or alone in her dorm room. She avoids eating in front of others when possible. However, at least once or twice a week, her teammates all go out to lunch after practice. This usually requires her to order food in front of them and she feels very anxious about it. She has been ordering the same salad with dressing "on the side" for several months because that is what makes her feel the most comfortable. One of her teammates commented on her "same old salad" and asked why she never got anything else to eat. Everyone at the table got quiet and turned to look at her. The client reports that the comment made her feel embarrassed and ashamed, like everyone was laughing at her. You ask her how she responded in the moment and she shares that she just laughed it off, but internally, she felt very embarrassed and anxious. You explore this further by asking her what emotions arise when she is around food, particularly in social settings. She reports feeling ashamed for wanting to eat "fattening food" because of her father's comments about her size. She skipped the last team lunch because she was so anxious about someone drawing attention to her food choices again. She closes her eyes and takes a breath. When she opens her eyes, you can see that she is struggling to hold back tears. She says, "Everyone eats their food like it's no big deal. But it's a huge deal for me. It's all I can think about. I just want to be able to eat a meal without feeling guilty or like I'm going to get fat. I'm so tired of worrying about food all the time!"    You consider using exposure and response prevention techniques to address her fear and anxiety related to eating. You continue the session by identifying a list of foods and situations that trigger her anxiety and negative feelings about her body. You ask the client if she would like to meet with you for her next session right after practice and bring a lunch to eat in your office. She appears relieved and grateful to have a break from eating in front of her teammates.
Other Contexts: The client's parents divorced when she was six years old. Her mother remarried 12 years ago. The client has a younger half-brother who lives with her mother and stepfather. She is close to her mother, but "my stepfather is a different story." She reports that he is critical of her and often remarks on how she looks or what she is eating. She states that he has commented on her weight and body shape since middle school. Her mother tries to intervene, but her stepfather continues to be critical. She tells you she couldn't wait to graduate high school and move out of the house. She tells you, "I remember that when I went home for a visit during winter break during my freshman year, my stepdad had this shocked look on his face when he saw me. He told me I had gained so much weight that I didn't even look like myself anymore. I've never forgotten that. And it's not like he's the picture of health." Previous Counseling: The client has a history of anxiety. She saw a therapist for a few sessions in high school after being referred by her school counselor, but she did not feel comfortable with the therapist and refused to continue attending sessions. She did not receive a clinical diagnosis related to her anxiety. The client reports that she has been feeling more anxious lately and is struggling to cope with her anxiety. She says that she feels "on edge," and that makes it difficult for her to concentrate. She is interested in exploring therapy to manage her anxiety. Additional Characteristics: The client is currently on the school's basketball team. She was voted most valuable player two years in a row.  

Question: From a behavioral therapy perspective, what type of reinforcement would you use to prevent the client from developing an unhealthy reliance on eating lunch in your office instead of in public?
(A): Variable ratio intermittent reinforcement
(B): Fixed interval reinforcement
(C): Variable interval reinforcement
(D): Fixed-ratio reinforcement

Correct Answer: Variable ratio intermittent reinforcement
Explanation: Variable ratio intermittent reinforcement is the most effective schedule to reinforce a behavior. This kind of schedule results in high, steady rates of responding. Clients are persistent in responding because of the hope that the next response might be one needed to receive reinforcement. Therefore, the correct answer is (C)
Competency: counseling skills and interventions