CBT-T Clinical Note

CBT-T Session Note Date: 1 November 2024 Session #: 6 Treatment Stage: Middle Phase Focus Module (if used): Body Image Disturbance Scores: EDE-Q: Current 3.2 (Previous 3.8); BDI-II: Current 18 (Previous 22) --- Session Focus The primary therapeutic goals for this session were to review progress on increasing meal variety and to address emerging body image concerns related to recent weight restoration. --- Client Update Eating behaviour since last session: Client reports successfully incorporating two new foods into her weekly meal plan, specifically wholemeal bread and nuts, which she previously avoided. She notes reduced anxiety around meal times but still struggles with spontaneous eating. Emotional state: Client reports feeling generally more stable emotionally, with fewer depressive episodes. However, she expressed increased anxiety and self-consciousness about her body shape after trying on new clothes. Progress with food changes: Good adherence to the agreed food plan, with particular success in increasing portion sizes and variety. She did express some difficulty adhering to the snack schedule on busy days. Therapy-interfering behaviours: No significant therapy-interfering behaviours reported or observed this week. Client arrived on time and completed all assigned tasks. Body image concerns: Client reported significant distress regarding perceived changes in her body shape, particularly her abdomen. She spent more time checking her appearance in the mirror and comparing herself to others. Weight discussion: Weight was discussed in the context of recent restoration and its impact on body image. The client acknowledged the necessity of the weight gain for her physical health but expressed ambivalence emotionally. --- Summary of Session Check-in: Client reported a good week overall, with improvements in energy levels and reduced preoccupation with food, but highlighted increasing concerns about her body image. Parents reported observing the client engaging more in family meals. Weight & Health: Client's physical health remains stable. Weight trajectory is appropriate, indicating continued restoration. No acute medical concerns were identified. --- Clinical Observations Client presented with good eye contact and was generally engaged, though she became visibly distressed and tearful when discussing body image concerns, demonstrating fidgeting and a slumped posture. Family dynamics observed were supportive, with parents actively listening and offering reassurance. --- Formulation / Reflections Client continues to demonstrate good insight into the necessity of weight restoration for physical health, though the 'eating disorder voice' appears to be strengthening in the area of body image. Motivation for recovery remains high, but body image distress is now a significant maintaining factor that requires focused intervention. --- Therapist Process Notes Engagement: Client was highly engaged and forthcoming, particularly during the discussion of body image, despite evident distress. Therapist stance: A compassionate and validating stance was maintained, particularly when addressing the client's body image distress, while gently challenging unhelpful cognitive distortions. Obstacles/alliance ruptures: No significant obstacles or alliance ruptures occurred during the session. Use of formulation: The formulation was used to explain how weight restoration can trigger increased body image concerns, normalising the client's experience and linking it to the eating disorder's compensatory mechanisms. --- Tasks & Interventions • Agenda items: Review of meal plan adherence, discussion of body image concerns, introduction to cognitive restructuring for body image thoughts. • Review of food plan and behaviour change: Reviewed successful integration of new foods and brainstormed strategies for consistent snacking on busy days. • Psychoeducation: Provided psychoeducation on typical body changes during weight restoration and the concept of 'body neutrality' as a stepping stone to positive body image. • Behavioural strategies: Practised 'mirror exposure with compassionate self-talk' to reduce body checking behaviours. Assigned mindful eating exercise for one meal daily. • Body image work: Introduced cognitive restructuring techniques to challenge negative automatic thoughts about body shape and size. • Formulation used: Explained how the eating disorder uses body image concerns to maintain its hold, highlighting the importance of challenging these thoughts as part of recovery. • Therapy-interfering behaviours addressed: None explicitly addressed as none present. • Homework reviewed: Reviewed success in food variety and discussed challenges with spontaneous eating. --- Plan for Next Session • Continue body image work, focusing on identifying and challenging core beliefs about appearance. • Explore emotional regulation strategies for managing body image distress. • Review mindful eating practice and address any ongoing mealtime anxieties. Next Appointment: 8 November 2024 Focus: Deepening body image interventions and emotional regulation. --- Homework Tasks: Practice cognitive restructuring for negative body image thoughts (3 times daily); continue mindful eating for one meal; engage in 'mirror exposure with compassionate self-talk' for 5 minutes daily. Observation targets: Observe frequency and intensity of body checking behaviours; notice situations or thoughts that trigger body image distress. --- Risk & Safety Risk behaviours or health concerns: No acute risk behaviours identified. Body image distress is a concern but client reports no intent for compensatory behaviours or self-harm. Action taken: Reinforced safety plan if body image distress becomes overwhelming. Emphasised open communication regarding any urges or concerns.