Eating Disorders Obesity - American Counseling Association

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AMERICAN COUNSELING ASSOCIATION 5999 Stevenson Avenue • Alexandria, VA 22304 • Edited by Laura H. Choate A Counselor’s Guide to Prevention and Treatment Eating Disorders and Obesity Copyright © 2013 by the American Counseling Association. All rights re- served. Printed in the United States of America. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the written permission of the publisher. 10 9 8 7 6 5 4 3 2 1 American Counseling Association 5999 Stevenson Avenue • Alexandria, VA 22304 Director of Publications • Carolyn C. Baker Production Manager • Bonny E. Gaston Editorial Assistant• Catherine A. Brumley Copy Editor • Kathleen Porta Baker Cover and text design by Bonny E. Gaston. Library of Congress Cataloging-in-Publication Data Eating disorders and obesity: a counselor’s guide to prevention and treatment/edited by Laura H. Choate. pages cm Includes bibliographical references and index. ISBN 978-1-55620-319-0 (alk. paper) 1. Eating disorders—Patients—Counseling of. 2. Obesity—Treatment. I. Choate, Laura Hensley, editor of compilation. II. American Counseling Association. RC552.E18E28253 2013 616.85´2606—dc23 2012037876 A Counselor’s Guide to Prevention and Treatment Eating Disorders and Obesity iii Contents Introduction vii Laura H. Choate Acknowledgments xxi About the Editor xxiii About the Contributors xxv Section1 Foundations Chapter 1 Sociocultural Influences on the Development of Eating Disorders and Obesity 3 Linda Smolak and Caitlin Chun-Kennedy Chapter 2 Gendered Considerations in the Treatment and Prevention of Eating Disorders 21 Margo Maine and Douglas Bunnell Chapter 3 Clients of Color and Eating Disorders: Cultural Considerations 45 Regine M. Talleyrand Chapter 4 Ethical and Legal Issues in Counseling Clients With Eating Disorders 69 Laura H. Choate, Mary A. Hermann, and Leigh Pottle, With Jodi Manton Section2 Assessment and Practice Frameworks for Eating Disorders and Obesity Chapter 5 Assessment and Diagnosis of Eating Disorders 91 Kelly C. Berg and Carol B. Peterson iv Contents Chapter 6 Assessment, Consultation, and Intervention for Eating Disorders in Schools 119 Jennifer Maskell Carney and Heather Lewy Scott Chapter 7 Assessment, Conceptualization, and Intervention With Young Adult Women With EDNOS: A Framework for Practice 141 Alan M. Schwitzer With Constance Rhodes Section3 Effective Prevention and Early Intervention for Eating Disorders and Obesity Chapter 8 Preventing Childhood Obesity 169 Janet A. Lydecker, Elizabeth Cotter, Rachel W. Gow, Nichole R. Kelly, and Suzanne E. Mazzeo Chapter 9 Prevention of Eating Disorders in Children: The Role of the Counselor 201 Niva Piran Chapter 10 Eating Disorders Prevention With Adolescents and Young Adults 221 Heather Shaw and Eric Stice Chapter 11 Effective Prevention Programs in College and University Settings 241 Deanne Zotter and Justine Reel Chapter 12 Cognitive–Behavioral Therapy Guided Self-Help for Binge Eating: A Culturally Sensitive Minimal or Early Intervention Program 265 Fary M. Cachelin, Munyi Shea, and Frances A. Bono Section4 Effective Treatments for Eating Disorders and Obesity Chapter 13 Enhanced Cognitive–Behavioral Therapy Approach to Counseling Clients With Eating Disorders 287 Anthea Fursland and Hunna J. Watson v Contents Chapter 14 Interpersonal Psychotherapy for Clients With Eating Disorders 309 Heather L. Waldron, Marian Tanofsky-Kraff, and Denise E. Wilfley Chapter 15 Psychosocial Treatments for Obesity and Aberrant Eating Patterns in Youths 345 Kerri N. Boutelle and Stephanie Knatz Chapter 16 Dialectical Behavior Therapy for Clients With Complex and Multidiagnostic Eating Disorder Presentations 375 Anita Federici and Lucene Wisniewski Chapter 17 Family-Based Therapy for Children and Adolescents With Anorexia 399 Kim Hurst and Shelly Read Chapter 18 A Relational–Cultural Approach to Working With Clients With Eating Disorders 425 Heather Trepal, Ioana Boie, Victoria Kress, and Tonya Hammer Index 443 vii Introduction Laura H. Choate The idea for this edited book, Eating Disorders and Obesity: A Counselor’s Guide to Prevention and Treatment, originated from a variety of influences. First, my desire to compile this type of book stems from being a mother of elementary-age children who are exposed daily to harmful media im- ages of and messages regarding narrow cultural definitions of how they “should” look and act. Because I want my children and all others to be equipped with the skills they need to stay healthy and resilient in the face of the cultural pressures surrounding eating, weight, and shape, this book is dedicated to assisting counselors and their clients to become empowered to effect positive change in this area within the multiple systems (family, school, community) in which they are embedded. The origins of this book are also grounded in my professional experience as a licensed professional counselor and counselor educator. I have been involved in the prevention and treatment field in a variety of roles: I have counseled clients, supervised and taught graduate students, published articles regarding body image resilience and eating disorder (ED) treatment, and presented at local schools to adolescent girls as well as to professionals at state and national conferences. I have observed that counselors are often unclear as to their role in preventing EDs and obesity and in providing early intervention and treat- ment, and they often lack training in best practices in this field. Therefore, the overarching purpose of this book is to provide a much-needed resource specifi- cally targeted to counselors that provides accessible information practitioners can implement in their daily work with clients across the continuum of care. The book strategically includes chapters that address assessment, prevention, and treatment, including information for working with children and adults as well as with clients from diverse cultural groups. Goals for the Book I am not alone in acknowledging the pervasiveness of cultural pressures regarding eating, weight, and shape that leave very few individuals unscathed. viii Introduction In fact, researchers have claimed that individuals in Western society cur- rently live in a toxic culture that makes it increasingly difficult to maintain a healthy weight and a positive body image (Brownell & Horgan, 2004), and these negative forces have become even more intense in recent years. These pressures influence individuals to varying degrees depending on their genetic vulnerability and their exposure to environmental risks. The first goal of this book, therefore, is to provide a foundation for counselors who work with clients with initial problems in this area so that the typi- cal progression toward increased symptom severity may be interrupted. The spectrum of client concerns in the area of EDs and obesity is broad. Many people experience body dissatisfaction, and women in particular are said to have a “normative discontent” with their bodies (Rodin, Silberstein, & Striegel-Moore, 1984). Of these individuals, some might progress to engaging in disordered eating practices such as excessive dieting or binge eating that can lead to weight gain or obesity. At the other end of the con- tinuum, others will have progressed to life-threatening EDs or obesity that significantly impairs their life functioning. Counselors need the preparation to recognize the signs and symptoms related to eating- and weight-related problems and the skills to respond according to client needs, whether it be a primary prevention program held in a school setting or a referral for inpatient hospitalization for a client who is emaciated from anorexia. In addition to addressing client needs across the continuum, a second goal of the book is to provide essential information regarding a client popula- tion that is increasing not only in number but also in clinical severity and complexity, making it highly likely that counselors will work with clients who have these concerns. Despite increased awareness and research initia- tives regarding EDs and obesity in recent years, rates of body dissatisfaction, disordered eating, rates of obesity, and problems with body weight and shape continue to increase across the life span. This increase is of concern in that the large number of individuals who experience current eating- and weight- related concerns are at risk for the future development of full-syndrome EDs and obesity. For example, the 2011 Youth Risk Behavior Surveillance survey found that 46% of all 9th to 12th graders and 61% of girls in particular were actively trying to lose weight (Centers for Disease Control and Prevention, 2012b). Binge eating has increased among adolescents in recent years, with between 20% and 60% in community samples reporting episodes of binge eating (Hudson, Hiripi, Pope, & Kessler, 2007). Young adult women are at particularly high risk for eating-related concerns; as many as 10% to 15% experience disordered eating such as excessive dieting and binge eating on a regular basis, and rates are even higher among college women (Hudson et al., 2007; Stice, Marti, Shaw, & Jaconis, 2009). Obesity rates are also increas- ing rapidly in the general population, with 69% of adults and one third of children in the United States being classified as overweight or obese (Ogden, Carroll, Kit, & Flegal, 2012). In addition, obesity rates among children and adolescents have more than tripled in the past 30 years (Centers for Disease Control and Prevention, 2012a). ix Introduction These high rates are also concerning because both EDs and obesity are associated with significant medical and psychosocial impairment. EDs are chronic, putting clients at risk for future obesity, depression, suicide attempts, substance abuse, and morbidity risk (Crow et al., 2009; Swanson, Crow, Le Grange, Swendsen, & Merikangas, 2011), and obesity is related to an increased risk for a host of negative consequences in both childhood and adulthood, including cardiovascular disease, diabetes, and increased mortality risk (National Heart, Lung and Blood Institute, 1998). Therefore, these problems should remain a top priority for prevention and treatment. A third goal of this book is to provide valuable information about assess- ment, prevention, and treatment of clients of diverse cultural backgrounds. Although once considered a problem exclusive to White middle-class girls and women, research has indicated that eating- and weight-related prob- lems are not exclusive to any particular cultural group or gender; rather, they cut across gender, race, class, and sexual orientation. For example, African American and Latina women tend to experience binge eating at the same rates as White women (Alegria et al., 2007), and Asian American women report similar or higher rates of body dissatisfaction in compari- son to White women (Grabe & Hyde, 2006). In addition, rates of excess weight or obesity are highest among Black (82%) and Latina (76%) women (Flegal, Carroll, Ogden, & Curtin, 2010) when compared with those of other cultural groups. Because individuals from diverse groups are often hesitant to seek out counseling services for their problems and because counselors might inadvertently overlook these problems in ethnic minority clients (Kelly et al., 2011), the chapters in this book include ways in which counselors can tailor traditional programs to better meet the prevention and treatment needs of all clients. A final goal of this book is to provide foundational information for counselors, who typically receive minimal instruction in EDs and obesity prevention and treatment in their preparation programs. I regularly teach undergraduate and graduate courses on women’s issues in counseling and supervise students in practicum settings serving young adult clients, and I have observed how problematic these issues are for clients and how unprepared student counselors feel to address these concerns because of the lack of training in their graduate preparation programs. In presenting at state and national conferences during the past 15 years, I have heard counselors describe their motivation to obtain information regarding best practices in the field, yet they often do not perceive themselves as prepared to work with clients experiencing disordered eating symptoms and are unclear regarding their role in prevention or early intervention that might circumvent the onset of full-syndrome EDs or obesity. Despite the growing research base primarily established in the fields of psychiatry and clinical psychology, information on evidence-based prevention and treatment is clearly not well disseminated among coun- seling practitioners. This book, therefore, will provide assistance to the practitioner who might not have the resources to purchase numerous x Introduction primary sources or locate research studies. As busy professionals, most practitioners do not have time to integrate existing information from these multiple resources and to use them to inform their work (e.g., treatment manuals, journal articles, chapters from handbooks in other fields). In this book, research, prevention strategies, and treatment methods are all synthesized in a highly practitioner-focused manner, with practical steps and language specifically tailored to counselors. For all of these reasons, this is a book for all counselors, not just those for whom EDs or obesity are a specialty area of focus. All counselors need the knowledge to recognize and assess client problems related to eating, weight, and shape and the skills to provide research-based interventions based on the appropriate level of care. With proper training, counselors are ideally suited to implement the fundamental counselor competencies of prevention, early intervention, and treatments that are tailored to client needs. To be optimally successful, they need additional grounding in the literature, knowledge of research-based programs or treatments, and moti- vation to obtain supervised practice for their initial work with clients. My desire is that through this book, counselors can gain this knowledge and acquire the skills needed to provide effective interventions for clients across the continuum of care, regardless of their professional or clinical setting. As the reader will discover as he or she reads this book, the chapters are specifically selected and designed to open these doors for students and practitioners alike. I invited a diverse and distinguished group of authors to participate in this book project, all of whom were excited to share their current research and clinical recommendations with professional coun- selors. The authors are a mix of seasoned practitioners, researchers, and faculty members from a variety of mental health and medical disciplines who are actively serving in the ED and obesity prevention and treatment field in the United States, Canada, and two different hospital-based treat- ment centers in Australia. Several of the authors included in this volume also wrote articles in- cluded in the 2012 Journal of Counseling & Development special section on ED prevention and treatment. As the guest editor of that issue, I was excited to receive so many strong international contributions from par- ticipants. On the basis of the response, I decided that counselors would also benefit from a book specifically intended for their needs that could cover the special issue themes as well as other relevant areas. The issues raised in the special issue articles served as the book’s foundation. Next, I sought out other multidisciplinary authors with expertise in EDs and obesity prevention and treatment. I was surprised at the enthusiasm and support for the book I received from almost every author I contacted. To paraphrase Margo Maine, McGilley, and Bunnell (2010), many authors have a similar interest in bridging the research–practice gap and possess a desire to present their research in a practical and easy-to-disseminate format. In this book, counselors now have highly accessible information regarding foundational knowledge, assessment and conceptualization, xi Introduction effective prevention programs, and best-practice treatments that span the continuum of care. To supplement their reading, recommended resources are included in every chapter, as well as a summary of the highlights of each chapter. More important, case examples are included to help counselors visualize what the theory or treatment would look like in practice. I should note that in the spirit of flexibility, some authors chose to incorporate case material throughout their chapters, and others included the case example to conclude the chapter. Book Overview The book is divided into four sections: Section 1: Foundations; Section 2: Assessment and Practice Frameworks for Eating Disorders and Obesity; Sec- tion 3: Effective Prevention and Early Intervention for Eating Disorders and Obesity; and Section 4: Effective Treatments for Eating Disorders and Obesity. Section 1: Foundations Section 1 provides information for understanding the sociocultural context in which EDs and obesity occur. Counselors need a firm understanding of cultural influences and risk factors to assist in the assessment, prevention, and treatment planning for these problems, including how interventions must account for environmental influences (e.g., media, family, peers) as well as for differences in gender and race and ethnicity. Ethical and legal considerations to increase counselor competence in this area are also explored. First, Linda Smolak and Caitlin Chun-Kennedy address the role of so- ciocultural influences in the development of body image disturbance and disordered eating symptoms, two of the strongest risk factors for EDs and obesity. They discuss the influences of media, peers, and parents as three primary sociocultural agents operating to shape body image development and describe individual differences regarding individuals who are most vulnerable to these influences. In Chapter 2, Margo Maine and Douglas Bunnell coauthor a chapter on gender and its impact on the prevention and treatment of both women and men with EDs. Because gender is a leading risk factor for the development of EDs, understanding how current gender role development affects an individual’s risk and how gender-based factors can maintain and reinforce eating problems is important. Maine and Bunnell also address gender differences in the expression of EDs and provide counseling strategies for providing gender-sensitive treatment to both men and women who experience disordered eating. Chapter 3 examines the importance of cultural influences through Regine M. Talleyrand’s discussion of EDs and obesity in people of color. As discussed previously, eating- and weight-related problems are more common among people of color than previously thought, and counselors have an ethical responsibility to detect and assess for these problems in their clients. In her chapter, Talleyrand reviews existing research conducted xii Introduction with specific cultural groups and discusses cultural factors that might put a client at risk for the development of ED symptoms and obesity. She also provides counseling strategies to help counselors deliver more culturally sensitive assessment, prevention, and treatment for clients of color. A final foundational chapter in Section 1 highlights important ethical and legal concerns when working with clients with EDs. Although clients with other mental health symptoms generally want to be rid of their problems, clients with EDs are frequently opposed to seeking treatment or altering disordered eating behaviors. In Chapter 4, I, Mary A. Hermann, and Leigh Pottle explore the ethical and legal complexities involved for counselors who work with clients who do not want to change life-threatening behav- iors. Counselors must carefully balance the need to respect clients’ ability to make their own life decisions while also fulfilling their own duty to protect clients from self-inflicted harm. The chapter also reviews coun- selors’ ethical duty to increase their self-awareness and to practice within their own scope of competence. The authors also review the issue of client autonomy in detail, describing issues related to informed consent and treatment decision making. The use of an ethical decision-making model is also demonstrated through a case example authored by Jodi Manton, a master’s degree candidate at Louisiana State University. Section 2: Assessment and Practice Frameworks for Eating Disorders and Obesity Assessment of client concerns is critical in identifying problems, conceptu- alizing client concerns, and conducting effective prevention and treatment planning. This section includes criteria from the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev., or DSM–IV–TR; American Psychiatric Association [APA], 2000) as well as the most recent proposed guidelines for the fifth edition of the DSM (DSM–5; American Psychiatric Association, 2012) to guide the discussion of assessment. Next, it includes chapters on two frameworks for guiding intervention decisions so that counselors can be more informed about determining where a client might need to enter the continuum of care, which ranges from prevention to intensive treatment. In Chapter 5, Kelly C. Berg and Carol B. Peterson provide a careful overview of both the DSM–IV–TR and the DSM–5 diagnostic criteria for the ED spectrum. Because eating- and weight-related concerns are so com- mon, Berg and Peterson recommend that assessment for EDs be integrated into all initial intake interviews, and they provide detailed descriptions for incorporating screening questions into a clinical interview. They also address special considerations for assessment and diagnosis of EDs, in- cluding working with children (who might not be developmentally capable of understanding typical screening questions) and with clients of color. Many eating- and weight-related problems emerge during the later childhood and adolescent years, indicating that youths experiencing these concerns spend most of their waking hours attending school. It makes xiii Introduction sense, then, that school counselors can play an important role in detecting the early onset of eating issues and in serving as a resource to ensure that student needs are met. In Chapter 6, Jennifer Maskell Carney and Heather Lewy Scott provide information for school counselors on identifying, as- sessing, and intervening with students who have eating- and weight-related concerns. Specifically, they provide school counselors with a framework guided by the American School Counselor Association’s National Model for conceptualizing and providing interventions for client concerns across the continuum of care, ranging from body image concerns, disordered eating (including binge eating, which leads to obesity), and EDs. Although Carney and Scott’s chapter focuses specifically on school- based intervention and referrals, in Chapter 7, Alan M. Schwitzer presents a framework for assessing and planning community-based interventions for young women with eating disorder not otherwise specified. Because this disorder is by far the most common ED, Schwitzer provides a model for working with clients who have it, including assessment guidelines, case conceptualization strategies, and a menu of counseling responses for prevention, early intervention, and treatment. Schwitzer’s chapter is unique in that it is supplemented by journal entries and writings of con- tributor Constance Rhodes (author of Life Inside the “Thin” Cage; 2003), who writes vividly about her personal experience and recovery from ED not otherwise specified. Section 3: Effective Prevention and Early Intervention for Eating Disorders and Obesity Because EDs and obesity are preventable public health concerns, this sec- tion of the book includes important chapters on prevention. Prevention is highly preferable to remediation and treatment in that prevention efforts can be successfully implemented in the childhood and adolescent period before serious problems occur. Prevention and early intervention are foundational to the practice of professional counseling, and counselors are well suited to provide prevention programs for schools and communities. This section includes two chapters on the prevention of EDs and obesity in children, two chapters on prevention in young adults and college stu- dents, and a final chapter regarding a culturally adapted guided self-help program that has demonstrated effectiveness with a community-based group of Mexican American women. Janet A. Lydecker, Elizabeth Cotter, Rachel W. Gow, Nichole R. Kelly, and Suzanne E. Mazzeo’s focus in Chapter 8 is on the prevention of obesity in children and adolescents. They provide evidence that the prevention of pediatric overweight and obesity should be a public health priority because of its potential short- and long-term medical and psychological consequences. In their chapter, the authors describe primary prevention interventions that can be implemented for all youths, including school- based interventions (changing school meals, vending machines, physical education), government policies (e.g., changing restrictions on media, food xiv Introduction industry, pricing), and community-based interventions (e.g., food access and physical activity in local neighborhoods, addressing barriers related to culture and food or physical activity). They also examine secondary obesity prevention programs that target youths who are at risk of becom- ing overweight or obese. In particular, they describe the counselor’s role as a behavioral specialist, using motivational interviewing strategies and family-based interventions in providing support for realistic goal setting in the areas of nutrition and physical activity. In Chapter 9, Niva Piran discusses the importance of a counselor’s role in preventing EDs in children. Because an increase in disordered eating symptoms and ED problems is occurring at younger ages, Piran asserts that preventing these problems from developing in children is far preferable to the complex treatment that is required when eating-related problems become entrenched in adolescence and early adulthood. Rather than focusing on the symptom level, Piran emphasizes the necessity of prevention programs that target the multiple systems in children’s lives, including broader social forces that operate in the school and community environment. Piran details her emerging developmental theory of em- bodiment, which explicates the array of social experiences that shape the development of body image. After detailing this model, she then presents strategies for early intervention and prevention programs that are framed by an ecological developmental perspective. In Chapter 10, Heather Shaw and Eric Stice address the prevention of EDs in older adolescents and young adults. After providing a thorough overview of ED prevention research, the authors highlight examples of ef- fective universal, selective, and indicated prevention programs. Next they provide a detailed description of the Body Project, an empirically supported dissonance-based secondary prevention program in which young women at risk for EDs because of body image concerns spend four sessions critiquing the thin ideal for women through verbal, written, and behavioral exercises (Stice, Mazotti, Weibel, & Agras, 2000). The Body Project groups are highly applied and interactive, requiring participants to learn new skills through in- session exercises, homework, and increased commitment to change through participation in motivational enhancement exercises. Deanne Zotter and Justine Reel (Chapter 11) turn readers’ attention to the prevention of eating- and weight-related concerns in college and university settings. They provide a review of disordered eating behaviors and body image concerns in college and university populations, including those that occur in subpopulations most at risk for these problems: sorority women, college athletes, and students majoring in health and physical education. The authors describe research-supported prevention efforts designed specifi- cally for university settings including Internet-based programs and tailored prevention programs for specific at-risk college-based groups. Finalizing the section on prevention is a chapter on an indicated preven- tion program for individuals who have early-onset eating- or weight-related problems. In Chapter 12, Fary M. Cachelin, Munyi Shea, and Frances A. xv Introduction Bono present a culturally sensitive indicated prevention program (cogni- tive–behavioral therapy guided self-help) for clients with early-onset bulimia nervosa and binge eating disorder. Cachelin and colleagues review the structure, contents, and counselor’s role in these programs and describe how they adapted the program specifically for a group of Mexican Ameri- can women. This type of early intervention is ideal for clients from diverse cultural groups who may have developed initial symptoms but might not be ready or willing to attend individual counseling. Section 4: Effective Treatments for Eating Disorders and Obesity For clients who are in need of more intensive approaches than the prevention and early intervention programs described in the previous sections, Section 4 addresses the current evidence-based and recommended psychosocial outpatient treatments for EDs and obesity (APA, 2006; Wilfley et al., 2007), which are also those that are most likely to fall within counselors’ scope of practice. EDs and obesity generally necessitate a multidisciplinary approach to treatment, including counseling, medical monitoring, medication, or even hospitalization. For children and adolescents, family involvement is also deemed essential (APA, 2006; Epstein, Wing, Koeske, & Valoski, 1987). Despite these commonalities, and although many of the treatment approaches described in this section have theoretical concepts and treat- ment components that overlap, several distinct approaches to effective treatment exist; some require detailed attention to changing disordered eating patterns through monitoring and behavioral change projects (e.g., enhanced cognitive–behavioral therapy [CBT–E]), and others do not at- tend to the eating patterns at all but focus on the interpersonal problems that purportedly drive the behavior (e.g., interpersonal therapy, relational cultural therapy). It is therefore important for counselors to review the treatment approaches described here carefully, note the research findings regarding what works best for which particular subpopulation of clients, and implement the treatment only after obtaining additional reading and appropriate supervised practice. In Chapter 13, Anthea Fursland and Hunna J. Watson focus on CBT–E (Fairburn, 2008), a treatment appropriate for all EDs because of its trans- diagnostic nature. It has received strong research support in clinical and community trials, and the original cognitive–behavioral therapy (CBT) for bulimia nervosa (Fairburn, Marcus, & Wilson, 1993) is considered the gold standard treatment for bulimia nervosa and binge eating disorder (APA, 2006). In this chapter, the authors review the CBT–E model for conceptu- alizing EDs, describe specific strategies for addressing disordered eating (i.e., normalization of eating, elimination of diets and binges), and provide cognitive strategies to assist the client with decreasing the importance of weight and shape in determining his or her worth and value. Heather L. Waldron, Marian Tanofsky-Kraff, and Denise E. Wilfley pro- vide in Chapter 14 a detailed overview of interpersonal therapy as adapted for working with clients with bulimia nervosa and binge eating disorder.