Running head: EATING DISORDERS AND CT 1

Eating Disorders Among Adolescents and

the use of Cognitive Therapy
Lyndsey G. Hepworth
Seattle University

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Abstract
This paper will focus on eating disorders in adolescents and discuss a) the data and
demographics surrounding those with eating disorders, b) the diagnostic criteria, characteristics,
and symptoms of the specific eating disorders anorexia nervosa and bulimia nervosa, c) cognitive
therapy and its fit with eating disorders, d) two specific counseling techniques counselors and
clients can use, e) a creative role-playing and guided imagery intervention and f)
recommendations for professional counselors. The focus is on adolescents but there is an
inclusion of information on eating disorders in the specific populations of children who are pre-
pubertal and athletes.
Keywords: eating disorders, anorexia nervosa, bulimia nervosa, eating disorders not
otherwise specified, cognitive theory, cognitive-behavioral therapy

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Eating Disorders Among Adolescents and
the use of Cognitive Therapy
Children and adolescents do not have it easy. As adults we often wish going back to the
easy days of a carefree and play-filled life. But was it really that easy? It was a time of
learning about your surroundings, while learning about yourself. There were physical changes,
awkward stages, and pressure from parents, teachers, and relentless peers. This can be a
confusing time for children and some get wrapped up in focusing on and perfecting their bodies.
This drive towards the perfect body can become unhealthy and lead to an eating disorder. This
paper will focus on eating disorders in adolescents and discuss a) the data and demographics
surrounding those with eating disorders, b) the characteristics and symptoms of the specific
eating disorders, anorexia nervosa and bulimia nervosa, c) my theoretical orientation and its fit
with eating disorders, d) two counseling techniques counselors and clients can use, e) a creative
role-playing and guided imagery intervention, and f) end with my recommendations for
professional counselors.
Extent of the Problem
There is an agency for counselors to be knowledgeable and prepared to work with
students who are struggling with body issues and eating disorders. Anorexia nervosa has the
highest mortality rate of any psychiatric disorder and fifteen percent of women suffer from a
diagnosable eating disorder at some point in their lives (Fursland et al., 2012). The numbers are
astonishing, one half of adolescent girls and one third of adolescent boys report in engaging in
unhealthy weight loss strategies, including fasting, vomiting, and taking laxatives (Choate,
2012, p. 259). School counselors and other school administrators need to be aware of the
physical signs of eating disorders because the peak onset is in adolescence, with anorexia
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nervosa often developing somewhat earlier than bulimia nervosa. Despite the age of peak onset,
body dissatisfaction and eating disorders can present in children and older adults (Fursland et al.,
2012). Historically, people thought that only European American girls and women suffered from
eating disorders, but they are becoming increasingly common in men, members of other ethnic or
racial groups, and the LGBTQ population (Choate, 2012). These facts and statistics highlight the
need for school counselors to be knowledgeable and skillful in prevention and treatment of
eating disorders. Often students come into counseling presenting with issues of anxiety,
depression, or relationship problems, when they are also having issues with eating. There is a
high comorbidity rate between eating disorders and other mental health issues. Counselors need
to be able to assess for eating disorders within a standard session so the underlying problem is
not overlooked (Choate, 2012). In the school system counselors will need to know how to assess
and work with adolescents dealing with body image issues and be aware of disordered eating in
children and athletes.
Although this paper is focused on adolescents and eating disorders, it is important to
understand the presence of eating problems in children. After all, the second most common
diagnosis for children in psychiatric inpatient units is an eating disorder (Smolak & Thompson,
2009). Children are most often diagnosed with eating disorder not otherwise specified (EDNOS)
because the diagnostic criteria for anorexia nervosa and bulimia nervosa are not aimed at
prepubertal children. Problems with eating in children are extremely dangerous because they are
still physically and neurologically growing. Restrictive eating may interfere with bone growth
and neuron development (Smolak & Thompson, 2009). No matter the age of the student it is
important to assess for eating disorders because, failure to diagnose and treat an eating problem
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early in its development may reduce the childs chances for recovery (Smolak & Thompson,
2009, p. 7). Being knowledgeable of disordered eating in children and early intervention is key.
In the school system it is also important to be aware of athletes and their eating. Athletes
tend to be perfectionists, goal oriented, and achievement driven, which is similar to the typical
personality of people with eating disorders, which may place them at a greater risk for
developing an eating disorder. Disordered eating is more prevalent in sports that emphasize a
low body weight or lean physique (i.e., thin-build sports) than those in which a low body weight
is not considered advantageous (Beals, 2004, p. 36). Sports that are judged, such as gymnastics,
dance, and figure skating, tend to place athletes at a higher risk for an eating disorder. Sports
with weight classifications (weightlifting, rowing, wrestling) and sports where low weight is
advantageous (long distance running and jumping) also place athletes at higher risk (Beals,
2004). Naturally, the sport setting increases body awareness, especially for female athletes
wearing revealing uniforms. The pressure to maintain a low body weight can stem from self or
external sources such as coaches and teammates. It is important for athletes to be aware of their
susceptibility to eating disorders and to practice healthy eating habits. Counselors should be
aware of the pressure athletes are under and help to advocate for a healthy lifestyle.
Behavioral Characteristics
The Diagnostic and Statistical Manual for Mental Disorders (4
th
ed.; American
Psychiatric Association [APA], 1994) recognizes two specific diagnoses, anorexia nervosa and
bulimia nervosa. It also includes an eating disorder not otherwise specified (EDNOS) category
when clients or patients do not meet the criteria for a specific eating disorder. There are two
types of anorexia nervosa, the restricting type where the person does not engage in binge-eating
or purging behavior and the binge-eating/purging type where the person has regularly engaged in
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binge-eating or purging behavior (APA, 1994). Bulimia nervosa also has two types, the purging
type and nonpurging type. The person with the purging type engages in self-induced vomiting
and the misuse of laxatives or other products for weight loss, while the person with the non-
purging type does not engage in these behaviors and uses other compensatory behaviors such as
exercise or restricting food (APA, 1994).
The diagnostic criteria for anorexia nervosa include a) refusal to maintain a healthy body
weight based on age and height, b) having an intense fear of gaining weight or becoming fat, c) a
disturbance in the way ones body is experienced, and d) amenorrhea, or the absence of at least
three consecutive menstrual cycles for females that are postmenarcheal (APA, 1994, p. 544).
The diagnostic criteria for bulimia nervosa includes a) recurrent episodes of binge eating where
the person eats a larger than normal meal and has a sense of lack of control over the binge eating
episode, b) recurrent inappropriate compensatory behavior to prevent weight gain, such as
excessive exercise, self-induced vomiting, and laxatives, c) the binge eating and compensatory
behaviors occur at least twice a week for three months, d) the persons self evaluation is based on
body shape and weight, and e) the disturbance does not solely occur during episodes of anorexia
nervosa (APA, 1994, p. 549). To meet the diagnostic criteria for an EDNOS, you must not meet
the criteria for the specific disorders, anorexia nervosa and bulimia nervosa.
An eating disorder that is not recognized by the DSM-IV is binge eating disorder. This
disorder is characterized by recurrent episodes of binge eating in the absence of the regular use
of inappropriate compensatory behaviors characteristic of Bulimia Nervosa (APA, 1994, p.
550). The proposed changes for the DSM-V (APA, 2011) that will be published in 2013 include
eliminating the amenorrhea requirement for anorexia nervosa and including binge eating disorder
as a formal eating disorder diagnosis (Berg, Peterson, & Frazier, 2012). These changes will
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decrease the amount of patients diagnosed with EDNOS, and increase the prevalence of anorexia
nervosa and bulimia nervosa.
In addition to the diagnostic criteria for anorexia nervosa and bulimia nervosa, there are
other important symptoms and physical cues that are important to be aware of when working
with adolescents. Symptoms and signs of anorexia nervosa include, but are not limited too:
Personality: often are perfectionists and seek control.
Psychological: fear of weight gain, dishonesty about eating, at risk for other mental
health illnesses, and ritualistic eating patterns.
Health consequences: anemia, loss of hair, yellowish skin, constipation, dehydration,
osteoporosis, possible damage to the heart and brain, irregular sleep patterns, brittle nails
and change in skin complexion, fatigue and lack of motivation, and feeling cold.
Physical cues: dramatic weight loss, bagging clothing, skipping meals, going to the
bathroom during meals, and unusual eating behavior.
Symptoms and physical cues specific to bulimia nervosa include, but are not limited too:
Personality: impulsive type.
Psychological: fear of weight gain, preoccupation with weight, and presence of other
mental health illnesses.
Health consequences: sore throats and worn-away tooth enamel, discolored or callused
fingers, heart attacks, acid reflux, dehydration, stomach cramps, diarrhea, and swelling of
lymph glands.
Physical cues: weight loss, going to the bathroom after meals, difficulty eating in front of
others, excuses to avoid meals, and consistent use of mints or gum after using the
bathroom.
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There are many characteristics and signs to be looking for with people with eating
disorders. The above list is not all-inclusive, but is meant to shed light on the various
characteristics of disordered eating not included in the diagnostic criteria for specific eating
disorders in the DSM-IV (APA, 1994). When eating disorders are severe and left untreated,
people can collapse, faint, or even die; it is essential for those who think they have a problem to
seek help and for friends to speak up. Counselors should be trained and prepared to work with
clients who suffer from eating disorders.
Theory and Counseling Strategies
Theoretical Orientation
Cognitive-behavioral therapy (CBT) is the treatment of choice when working with clients
who are bulimic or have EDNOS (Murphy, Straebler, Cooper, & Fairburn, 2010). I mainly
align with cognitive theory, but see the benefits of incorporating behavioral therapy for an even
more thorough approach. I have chosen to orient myself with Aaron Becks cognitive theory
(CT) because of its broad application, it is time-limited in nature, and because I believe that all
types of psychological dysfunctions include maladaptive thought processes. It is our thoughts
that change our feelings, which produce our behavior. External forces such as the environment
and larger systems play a role in dysfunction, but in that dysfunction there will be faulty thought
processes that, when addressed, can help alleviate some of the distress caused by those forces.
All thought-focused treatment systems believe that thoughts come first and then feelings and
behaviors. As humans we have a constant flow of thoughts that cannot be turned off; this has
been termed our stream of consciousness (Seligman & Reichenberg, 2010). Through our stream
of consciousness people can develop adaptive or maladaptive thought processes.
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The basic process of change for anyone in CT is cognitive restructuring, or identifying
faulty cognitions and changing them to adaptive, more realistic thoughts. Cognition is defined
as that function that involves inferences about ones experiences and about the occurrence and
control of future events (Alford & Beck, 1997, p. 14). The key to this definition is control of
future events; helping your client to identify, evaluate, and modify their dysfunctional thoughts
and beliefs about eating can prevent future dysfunctional emotions and behaviors. When
working with clients who have an eating disorder, however, it is extremely important to focus on
behaviors as well, making CBT the therapy of choice.
In future practice I plan on using cognitive theory, cognitive-behavioral therapy,
multicultural counseling, and counseling for social justice. Looking at the issue of eating
disorders through the lens of each of these theories, the behavioral therapy will help the
unhealthy eating behaviors and cognitive theory will target the maladaptive, negative thought
processes that fuel those behaviors. By keeping the clients worldview in perspective I am
building rapport and trust with the client and am understanding how their eating behaviors are
accepted in their culture. For example I could ask myself, is eating a huge feast acceptable for
them or is eating only after the men have eaten the accepted way? With television and social
media everywhere it is important to explore with the client the role media has in their body
dissatisfaction. I believe that my counseling lenses are effective approaches when working with
clients suffering from an eating disorder.
Cognitive Therapy Counseling Technique
Cognitive therapy is a structured approach that utilizes specific techniques, interventions,
and activities to be completed outside of session. Most techniques are aimed at changing
cognitions. Some of these techniques include thought-stopping, self-talk, mental and emotional
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imagery, and cognitive rehearsal (Seligman & Reichenberg, 2010). In the school setting
common techniques include collaborative problem solving, thought records, thought bubbles,
guided discovery, the Three Cs, coping cards, and the reverse role play (Creed, Reisweber, &
Beck, 2011, p. 57). Drawing thought bubbles is an effective way for younger children to
understand and see how thoughts work.
When practicing CBT with a client who has an eating disorder I would encourage
journaling so that thoughts and behaviors can be brought to more attention. To help identify
thoughts I would teach my client about the Three Cs and ask him or her to record instances of
use in his or her journal. To help identify problematic behaviors I would teach my client the
ABCs or antecedent/activating event, behavior, and consequence.
The Three Cs is an approach used to help students work through their maladaptive
thinking patterns. When using the Three Cs you will be asking [the student] to identify the
thought that came before [his or her] emotion (catching), reflect on how accurate and useful the
thought is (checking), and then change the thought to a more helpful or accurate one as needed
(changing) (Creed et al., 2011, p. 71). Once the student understands the Three Cs, catching,
checking, and changing, you can assign homework to practice this technique out of session.
Homework or activities to be completed in-between sessions is a necessary component of CT
that promotes skills acquisition and its application in real-world contexts. For real progress the
client needs to be able to be aware of and capable of changing thoughts such as, I hate my body,
I am not eating today. The client would hopefully catch their thought of hate, check to see if
this is a useful or healthy thought, and change this thought to a more realistic, healthy one.
Journaling using the ABC technique will allow clients to recognize when or how they
develop the urge (antecedent or activating event) to engage in unhealthy behavior such as
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purging (behavior) and see the aftermath of their actions (consequences). In classrooms the
ABC chart is often completed by teachers, but can be a helpful tool for individuals to complete
themselves to help identify patterns or themes of their thinking and behaving. This information
is valuable to both the client and counselor and can help move therapy sessions forward. In this
theory it is essential for the client to have clear goals; the goals for the student depends on their
eating disorder, severity, and willingness to engage in the change process, but in general goals
are realistic, attainable, and measurable. Two ways to set a goal around eating disorders, among
many others, are through questioning and imagery. The counselor may ask, What changes
would you like to make? or use imagery, similar to the solution-focused miracle question, and
ask the client to describe a scene where they are feeling significantly better. Counselors can start
a goal list with students as early as their first session and encourage journaling between sessions
to help keep progress moving forward. This will help the counselor gain a better understanding
of the client and his or her ways of thinking about their body and how he or she engages in
disordered eating.
Creative Counseling Technique
The expressive arts can seamlessly be integrated into traditional CBT; CBT techniques
such as journaling and guided imagery are also techniques in the expressive arts (Degges-White
& Davis, 2011). In both the CBT and the expressive arts, the common goal is for the client to
achieve behavioral change (Degges-White & Davis, 2011, p. 45). One way this behavioral
change can occur is through role-playing in a play that has two acts separated by a period of
relaxation and guided imagery. During this role-play the client will be able to act out his or her
inner thoughts and feelings through behavior. No materials are necessary for this play, but
having a doll or something to talk too may be helpful for the client. This intervention may be
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emotionally heavy for clients and going at an appropriate pace for the client is necessary; the
intervention can take one session or be spread out between sessions.
For the first act ask your client to focus on their constant stream of consciousness, or
constant flow of thoughts they go through when engaging in unhealthy eating behavior. Guide
this process by saying what are you telling yourself when restricting food, purging, binge eating,
taking laxatives, or exercising too frequently (include whichever are appropriate for the client)?
This can look different ways for clients; some may choose to dialogue their thoughts, some may
touch the parts of they body they are unhappy with, and some may choose to dramatize their
thoughts by acting them out. Either way the clients engage in the first role-play, have them focus
on their thoughts before and when they are practicing maladaptive thoughts and unhealthy eating
behaviors. This role-play will give the counselor a plethora of information about the client and
his or her viscous cycle of disordered eating.
Before the second play, client and counselor will go through a guided imagery. Before
the guided imagery begins the counselor should ask the client to take five deep breaths and to
relax. During this guided imagery the counselor can create a scenario where the client is happy
with their body, similar to the concept of the miracle question, but the counselor is the one
painting the picture of a life where the client is content. The counselor can also use a guided
imagery script such as the one provided in the handout. The guided imagery is a time for the
client to imagine being happy and to recognize how that feels and is elicited in the body.
The second act is a time to act out the thoughts and feelings elicited in the guided
imagery. This will give the client a time to establish their current thoughts and feelings about
their body. It will also give them control in a more positive way than the typical engagement in
disordered eating habits. These acts and guided discovery are a time full of processing. There is
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no need to process what they client did or said, simply acknowledge the steps the client has taken
and use the information in future counseling sessions. This creative intervention should be
adapted to fit the needs and emotional readiness of the client.
Conclusion and Recommendations
As counselors working in the k-12 system we will have clients that are struggling with
body image and diagnosable eating disorders. There is an agency for counselors to be
knowledgeable and prepared to work with students who are struggling with body issues. It is our
job to be educated around prevention and intervention for these students. Cognitive-behavioral
techniques such as the Three Cs, the ABC model, journaling, and role-playing are effective
tools that can be used in and outside of session. If multiple kids are struggling with body image I
suggest providing a group workshop on body image or a guidance unit on healthy eating and
behaviors. Eating disorders are present in children, athletes, and adolescents; it is our job to be
educated, creative, and helpful in their disordered eating journey to recovery.

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References
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