Collaborating with Outside Providers

Case Analysis – Collaborating with Outside Providers
Prior to beginning work on this assignment, read the PSY650 Week Three Treatment Plan Preview the document and Case 9: Bulimia Nervosa in Gorenstein and Comer (2014). Please also read the Waller, Gray, Hinrichsen, Mounford, Lawson, and Patient (2014) “Cognitive-Behavioral Therapy for Bulimia Nervosa and Atypical Bulimic Nervosa: Effectiveness in Clinical Settings,”Halmi (2013) “Perplexities of Treatment Resistance in Eating Disorders,” and DeJesse and Zelman (2013) “Promoting Optimal Collaboration Between Mental Health Providers and Nutritionists in the Treatment of Eating Disorders” articles.

Assess the evidence-based practices implemented in this case study. In your paper, please include the following.

Explain the connection between each theoretical orientation used by Dr. Heston and the treatment intervention plans utilized in the case.
Describe the cognitive-behavioral model of the maintenance of bulimia nervosa.
Explain why Rita was reluctant to participate in Dr. Heston’s request for her to keep a record of her eating behaviors. Use information from the Halmi (2013) article “Perplexities of Treatment Resistance in Eating Disorders” to help support your statements.
Recommend outside providers (psychiatrists, medical doctors, nutritionists, social workers, holistic practitioners, etc.) to the assist Rita in achieving her treatment goals. Use information from the DeJesse and Zelman (2013) “Promoting Optimal Collaboration between Mental Health Providers and Nutritionists in the Treatment of Eating Disorders” article to help support your recommendations.
Describe some of the challenges and ethical issues that Dr. Heston may encounter when working collaboratively with the professionals that you recommended. Apply ethical principles and standards of psychology relevant to your description of Dr. Heston’s potential collaboration with outside providers.
Evaluate the effectiveness of the treatment interventions implemented by Dr. Heston, supporting your statements with information from the case and two to three peer-reviewed articles from the Ashford University Library.
Recommend three additional treatment interventions that would be appropriate in this case. The recommended articles for this week may be useful in generating your response to this criterion. Justify your selections with information from the case.
The Case Analysis – Collaborating with Outside Providers

Must be 4 to 5 double-spaced pages in length (not including title and references pages) and formatted according to APA style as outlined in the Ashford Writing Center (Links to an external site.).
Must include a separate title page with the following:
Title of paper
Student’s name
Course name and number
Instructor’s name
Date submitted
Must use at least two peer-reviewed sources from in the Ashford University Library.
Must document all sources in APA style as outlined in the Ashford Writing Center.
Must include a separate references page that is formatted according to APA style as outlined in the Ashford Writing Center.

Cognitive-Behavioral Therapy for Bulimia Nervosa and Atypical Bulimic Nervosa:

Effectiveness in Clinical Settings

Glenn Waller, DPhil1* Emma Gray, DClinPsych2

Hendrik Hinrichsen, DClinPsych3

Victoria Mountford, DClinPsy4,5

Rachel Lawson, MA6

Eloise Patient, BSc7

ABSTRACT Objective: The efficacy of cognitive- behavioral therapy (CBT) for bulimic dis- orders has been established in research trials. This study examined whether that efficacy can be translated into effective- ness in routine clinical practice.

Method: Seventy-eight adult women

with bulimic disorders (bulimia nervosa

and atypical bulimia nervosa) under-

took individual CBT, with few exclusion

criteria and a treatment protocol based

on evidence-based approaches, utilizing

individualized formulations. Patients

completed measures of eating behav-

iors, eating attitudes, and depression

pre- and post-treatment. Eight patients

dropped out. The mean number of ses-

sions attended was 19.2.

Results: No pretreatment features pre- dicted drop-out. Treatment outcome was similar whether using treatment com-

pleter or intent to treat analyses. Approxi- mately 50% of patients were in remission by the end of treatment. There were sig- nificant improvements in mood, eating attitudes, and eating behaviors. Reduc- tions in bingeing and vomiting were comparable to efficacy trials.

Discussion: The improvements in this “real-world” trial of CBT for adults with bulimic disorders mirrored those from large, funded research trials, though the conclusions that can be reached are inevitably limited by the nature of the trial (e.g., lack of control group and therapy validation). VC 2013 Wiley Periodicals, Inc.

Keywords: bulimia nervosa; atypical bulimic disorders; cognitive-behav- ioral therapy; effectiveness

(Int J Eat Disord 2014; 47:13–17)


There is substantial evidence that cognitive- behavioral therapy (CBT) is efficacious in the treat- ment of adult women with bulimia nervosa and atypical bulimic disorders.1–7 However, that evi-

dence has come from funded research studies. Such findings are not necessarily generalizable to the wider range of clinical settings, due to factors such as the exclusion of comorbidity or atypical cases, treatment being delivered under highly stringent conditions, and the need to adhere strictly to proto- cols. Thus, such evidence of efficacy in the research environment needs to be translated into evidence of effectiveness in less specialized clinical practice, in order to avoid clinicians ignoring the evidence as being irrelevant to their client group.8 This attitude might explain the common omission of core techni- ques when delivering CBT for adults with eating dis- orders9 and the fact that only a minority of clinicians report using manuals when working with bulimia nervosa.10 There is evidence for the clinical applicability of research-based CBT for anxiety and depression.11,12 However, that is not the case in the eating disorders. Therefore, this study considered whether the efficacy of CBT for bulimic disorders (as shown by existing research trials) can be trans- lated into clinical effectiveness in routine clinical settings, where none of the exclusion- and protocol- based constraints outlined above apply.

Accepted 27 July 2013

*Correspondence to: Glenn Waller, Clinical Psychology Unit,

Department of Psychology, University of Sheffield, Western Bank,

Sheffield S10 2TN, UK. E-mail: 1 Clinical Psychology Unit, Department of Psychology, University

of Sheffield, Sheffield, Sheffield, England, United Kingdom 2 British CBT and Counselling Service, London, England, United

Kingdom 3 Sutton and Merton IAPT Service, South West London and St.

George’s Mental Health NHS Trust, Springfield University Hospital,

London, England, United Kingdom 4 Eating Disorders Section, Institute of Psychiatry, King’s College

London, London, England, United Kingdom 5 Eating Disorders Service, South London and Maudsley NHS

Foundation Trust, Denmark Hill, London, England, United

Kingdom 6 South Island Eating Disorders Service, Christchurch, New

Zealand 7 North Staffordshire Wellbeing Service, Newcastle-under-Lyme,

Staffordshire, England, United Kingdom

Published online 1 September 2013 in Wiley Online Library

( DOI: 10.1002/eat.22181 VC 2013 Wiley Periodicals, Inc.

International Journal of Eating Disorders 47:1 13–17 2014 13



All patients were treated in a publically-funded outpa-

tient eating disorder service in the UK. The only exclu-

sion criteria were psychosis, learning difficulties, or an

inability to work in English. The participants in the trial

were a case series of those patients with bulimic disor-

ders who opted to undertake CBT when assessed and

when treatment options were discussed. A small number

of patients opted to undertake a psychodynamic therapy,

while another group attended for assessment but

declined or failed to attend for treatment. However, the

numbers in these groups were not recorded. Therefore,

this is a study of those who opted to begin CBT, rather

than all who attended the clinic or who had bulimic dis-

orders. None were excluded from the trial due to missing

data (see below).

The sample entering treatment were 78 adult women

with bulimic disorders: 55 with bulimia nervosa (52

purging subtype; three nonpurging subtype) and 23 with

EDNOS involving bulimic behaviors (nine with subthres-

hold bulimia nervosa, involving bingeing and purging at

least once per week over three months; 10 with binge

eating disorder; and four with purging in the absence of

bingeing). None were in the anorexic weight range. All

were assessed using a semistructured interview proto-

col,13 and diagnosed using DSM-IV criteria.14 The mean

age of the sample at assessment was 27.8 years (SD 5

7.11) and their mean body mass index (BMI) was 22.1

(SD 5 3.26).

A minority of the bulimic sample (N 5 9) were receiv-

ing SSRI antidepressants (stabilized prior to treatment

and maintained throughout the treatment period) and a

small number had occasional dietetic reviews, but none

were receiving any other form of treatment in parallel

with CBT. A high proportion had some comorbidity

(major depressive disorder: 44% of cases; obsessive-

compulsive disorder: 26%; other anxiety disorders: 32%;

and substance misuse: 23%). The levels for anxiety and

depressive disorders are higher than in some efficacy

studies,3 but comparable for substance misuse.


Height and weight were measured objectively. Diaries

were used to assess frequency of bingeing and vomiting.

The women also completed measures of eating pathol-

ogy and depression at the beginning and end of


Eating Disorders Inventory. The EDI15 is a self-report

measure of eating and related attitudes. Scores are

responsive to changes over treatment. Scores…