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.  10th session During your last session with the client, she discussed the anxiety that she was feeling about going home for winter break in a few weeks. She told you that her mom and stepdad always prepare a large meal for the holidays, and the extended family members get together to eat. She expressed a desire to participate in the family festivities but concern about her mom and stepdad's lack of understanding about her illness. She told you, "I don't want to make anyone feel bad, but I just can't eat like everyone else. It's not only the food - it's the conversations and comments about my body that really bother me." You listened as she expressed her fear of disappointing her family and reassured her that is was okay to set boundaries and have conversations about food. Together, you brainstormed coping strategies to manage her anxiety. You also suggested that she bring a dish of food that she would be comfortable eating to the winter break gathering. At the end of the session, she asked if she could bring her parents to the next session in an effort to gain their support and to help them understand what she is going through. You agreed to her request and scheduled an appointment to meet with the client and her parents.    At the start of today's session, you introduce yourself to her parents and explain your role in helping their daughter. The client's mother tearfully shares that she had no idea her daughter was struggling so much and that she wishes she had picked up on the signs sooner. The stepfather appears quiet and reserved. You help guide a conversation between the client and her parents about her eating disorder and symptoms that she is experiencing. The client shares her fears, triggers, and struggles around food. Her stepfather speaks up and says, "I've heard enough. This is just ridiculous. You should just be able to eat, like everyone else. Your generation has gone 'soft' and started making up problems. There are people out there who don't have any food. When I was growing up, we had nothing. Your behavior is disrespectful." As he is talking, the client's mother is quiet and visibly uncomfortable. The client interjects, "Are you kidding? I'm the one who's being disrespectful?" She looks toward you and says, "When I'm home, he cooks these extravagant meals and refuses to let me leave the table until I've eaten what he's served me because it's 'wasteful to throw away food.' It's abuse! I feel like a captive when I'm at home." She looks back at her stepfather and says, "All I'm asking is that you understand what I'm going through and try to be a little more supportive." The stepfather's face turns red with anger, and he gets up to leave the room. You intervene and ask him to stay, offering a suggestion that you all take a few moments to reflect on what each person has shared before continuing the conversation. While the stepfather takes a break, you encourage the mother to open up and express her feelings. She reveals that she is scared of not being able to help her daughter and feels helpless in understanding how to come together as a family. You discuss ways that she can be supportive and provide an empathetic environment for her daughter.
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: Based on best practices for family therapy, how would you recommend structuring future sessions with the client and her parents?
(A): Propose bringing in a co-therapist to take the stepfather for individual work while you continue with the client and mother.
(B): Decline any further joint sessions to avoid exposing the client to further harm and conflict. Only meet with her individually.
(C): Hold joint sessions to resolve conflicts and teach communication skills together.
(D): Suggest individual sessions for each, then small joint sessions with the client and mother before full family sessions.

Correct Answer: Suggest individual sessions for each, then small joint sessions with the client and mother before full family sessions.
Explanation: Starting with individual sessions allows each family member to work on their concerns separately, optimizing progress. Small joint sessions for the client and mother can nurture their relationship before engaging the stepfather. This staged approach minimizes the risks of re-traumatization. Therefore, the correct answer is (C)
Competency: professional practice and ethics