submit the annotation of a qualitative research article on a topic of your interest (Burnout in Teachers). Narrative, ethnographic, grounded theory, case study, and phenomenology are examples of types of research designs or approaches used in qualitative research.

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his week, you will submit the annotation of a qualitative research article on a topic of your interest (Burnout in Teachers). Narrative, ethnographic, grounded theory, case study, and phenomenology are examples of types of research designs or approaches used in qualitative research.

An annotation consists of three separate paragraphs that cover three respective components: summary, analysis, and application. These three components convey the relevance and value of the source. As such, an annotation demonstrates your critical thinking about, and authority on, the source topic. This week’s annotation is a precursor to the annotated bibliography assignment due in Week 10.

An annotated bibliography is a document containing selected sources accompanied by a respective annotation of each source. In preparation for your own future research, an annotated bibliography provides a background for understanding a portion of the existing literature on a particular topic. It is also a useful first step in gathering sources in preparation for writing a subsequent literature review as part of a dissertation.

Please review the assignment instructions below and click on the underlined words for information about how to craft each component of an annotation.

It is recommended that you use the grading rubric as a self-evaluation tool before submitting your assignment.

Inquiry-Based Stress Reduction Meditation Technique for Teacher Burnout: A Qualitative Study Lia Schnaider-Levi1, Inbal Mitnik1, Keren Zafrani2, Zehavit Goldman3, and Shahar Lev-Ari1,4

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M I N D , B R A I N , A N D E D U C A T I O N

Inquiry-Based Stress Reduction Meditation Technique for Teacher Burnout: A Qualitative Study Lia Schnaider-Levi1, Inbal Mitnik1, Keren Zafrani2, Zehavit Goldman3, and Shahar Lev-Ari1,4

ABSTRACT— An inquiry-based intervention has been found to have a positive effect on burnout and mental well-being parameters among teachers. The aim of the current study was to qualitatively evaluate the effect of the inquiry-based stress reduction (IBSR) meditation technique on the participants. Semi-structured interviews were con- ducted before and after the IBSR intervention and were analyzed using the interpretative phenomenological analy- sis method. Before the intervention, the teachers described emotional overload caused by two main reasons: (1) multi- ple stressful interactions with students, parents, colleagues, and the educational system, and (2) the ideological load of their profession—trying to fulfill high expectations of performance and the manifesting educational values. Fol- lowing the intervention, the teachers described a sense of centeredness and a greater ability to accept reality. They reported improvements in setting boundaries, thought flexibility, and self-awareness. These improvements assisted them in coping with the complex and dynamic nature of their profession. These positive effects suggest that IBSR is an effective technique in reducing teachers’ burnout and promoting mental well-being.

1Department of Health Promotion, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University 2Begin High School 3Blich High School 4Center of Complementary and Integrative Medicine, Tel Aviv Medical Center

Address correspondence to Shahar Lev-Ari, Department of Health Promotion, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; e-mail: shaharl@tlvmc.gov.il.

Burnout is defined as a response to a chronic emotional strain due to dealing extensively with other human beings, particularly when having to deal with recurring problems as well as reduced coping resources (Maslach, 2003; Maslach, Jackson, & Leiter, 1996). Its components are emotional exhaustion, defined as a lack of mental resources due to an emotional overload; depersonalization, defined as an alien- ated and negative attitude toward the surroundings; and decreased personal accomplishment, defined as reduced abil- ity to accomplish desirable results due to lack of external or internal resources (Awa, Plaumann, & Walter, 2010; Emery & Vandenberg, 2010; Friedman, 1993; Maslach, 2003; Maslach et al., 1996). Burnout has been researched intensively in the field of education, and various studies have described its prevalence among teachers (Brackenreed, 2011; De Heus & Diekstra, 1999; Friedman, 2000; Honkonen et al., 2006; Luk, Chan, Cheong, & Ko, 2009; Schaufeli & Buunk, 2002), as well as its significant personal and social implications, such as low level of performance, reduced commitment to teaching, high turnover (Friedman, 1993; Gold & Roth, 1993; Melamed, Shirom, Toker, Berliner, & Shapira, 2006; Sorek, Tal, & Paz, 2004), and physical morbidity (Ahola, Väänänen, Koskinen, Kouvonen, & Shirom, 2010; Bauer et al., 2006; Honkonen et al., 2006; Melamed et al., 2006; Shirom, Toker, Melamed, Berliner, & Shapira, 2013).

Teachers need to maintain high levels of mental well-being in order to fit social expectations, professional expectations, and their own expectations (Awa et al., 2010; Pillay, Goddard, & Wilss, 2005). The optimal state of mental health, which is best described as “mental well-being,” related to health, optimism, contentment, hope, and hap- piness, is when an individual fulfills his/her capabilities and functions well under standard pressures of life so that he/she can be productive and effective and can contribute to society (Seligman & Csikszentmihalyi, 2000; World Health

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Organization, 2004). Promoting psychological well-being focuses on the individual’s positive and optimal functioning (Bolier et al., 2013; Keyes, 2007). Theorists have defined the nature of positive psychological functioning in a variety of ways; however, there is consensus around six common factors that need to be addressed in order to avoid mental weariness, frustration, anxiety, nervousness, depression, emotional exhaustion, and psychosomatic problems (Keyes, 2007; Ryff, 1989, 1995; Sin & Lyubomirsky, 2009; Tylee & Wallace, 2009; World Health Organization, 2004). These are self-acceptance, positive and reciprocal relationships with others, autonomy in thought and action (the ability to resist social pressure and to regulate behavior and thoughts according to personal standards), environmental mastery and competence (the ability to manage complex external surroundings, to choose or create contexts suitable to per- sonal needs and values), purpose in life, and personal growth and development.

The umbrella term of well-being promotion includes sev- eral types of intervention, including approaches such as the psycho-behavioral methods used in the corporate business world (e.g., cognitive behavioral therapy, coaching), posi- tive psychology intervention (PPI) methods (e.g., practical gratitude, art therapy, music therapy), and mindfulness tech- niques (e.g., meditation, breathing practice; NCCAM, 2010; Sin & Lyubomirsky, 2009; Tylee & Wallace, 2009).

Mindfulness-based interventions are designed to enhance the mind’s capacity to be aware of the present moment and to accept one’s current experiences without judgment or elaboration (Bishop et al., 2004; Kabat-Zinn, 1994). With- out compelling the suppression or alteration of emotions, mindfulness enhancement enables the individual to have greater control of thoughts and emotions while dismiss- ing old habits and automatic reactions (Chambers, Gullone, & Allen, 2009). Research has demonstrated that different forms of meditation can enhance well-being across diverse populations within (and beyond) the education sector. For example, student educators were taught simple meditation using sound as a focusing tool, and practiced it for 45 min per session, four times. Questionnaires filled by the par- ticipants who practiced this meditation have shown a sig- nificant reduction in their stress symptoms in the posttest measurements when compared to the control group in the domains of emotional, gastronomic distress, and behavioral manifestations (Elder, Nidich, Moriarty, & Nidich, 2014; Emery & Vandenberg, 2010; Kemeny et al., 2012; Ospina et al., 2008; Winzelberg & Luskin, 1999). Practicing tran- scendental meditation was reportedly effective on psycho- logical measures, such as stress and exhaustion, among spe- cial education teachers in the United States (Elder et al., 2014). Mindfulness practice of one and a half hours once a week during 10 weeks among teachers in Spain significantly enhanced well-being measures and the effective functioning

of teachers in stressful situations; positive effects persisted 4 months following the conclusion of the intervention pro- gram (Franco, Manas, Cangas, Moreno, & Gallego, 2010).

The ability to acknowledge and consider the emotions of others was shown to improve among intervention recipients during an intensive study of U.S. teachers receiving mind- fulness training combined with emotional adjustment. The participants also showed a decrease in blood pressure in con- junction with increases in mindfulness practice (Gold et al., 2009). A study conducted in Germany involving the prac- tice of breathing techniques showed participating teachers demonstrated an improvement in 9 out of 11 functional and emotional measures (Loew, Götz, Hornung, & Tritt, 2009). An intervention involving the practice of mindfulness-based stress reduction (MBSR) and the practice of tai chi was stud- ied in a school in Boston after being recommended and results showed it to be an effective technique for increasing peace of mind and improving the quality of sleep, focus, and well-being measures (Wall, 2005).

A direct link has been established between mindfulness- based techniques and enhanced brain activity in the frontal cortex areas that are responsible for focusing attention and positive prosocial emotional states, such as empathy, com- munication, and socialization (Davidson & McEwen, 2012; Goleman & Gurin, 1993). Davidson and McEwen (2012) described emotional capabilities, self-inspection, and mind- fulness as dynamic, acquired, and adaptive processes, which can be enhanced in the same manner as other skills in the fields of music, mathematics, and sports. Their study showed structural and functional changes in the brain as a result of cognitive therapy and training certain forms of meditation.

Practicing mindfulness or meditation enables the indi- vidual to be less reactive to negative experiences and more focused on positive aspects as the consequence of enhancing the activities of specific brain areas (Davidson, 1992; Lutz, Slagter, Dunne, & Davidson, 2008).

Taken as a whole, such studies demonstrate that, across multiple contexts and countries, well-being promotion tech- niques based on mindfulness can be used beneficially among teachers. However, broader and longer term research is still needed in order to establish the effectiveness of these techniques in burnout-related exhaustion prevention and treatment.

Inquiry-Based Stress Reduction Inquiry-based stress reduction (IBSR) is a meditation technique developed by Byron Katie in 1986. Its aim is to identify the thoughts that cause stress and suffering in a systematic and comprehensive way, and to meditatively “investigate” them by a series of questions and turnarounds. This technique does not require any intellectual, religious, or spiritual preparation, but rather a will to deepen and

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reach self-awareness (Katie & Mitchell, 2003). It has been practiced by many individuals worldwide (Landau et al., 2014; Lev-Ari, Zilcha-Mano, Rivo, & Geva, 2013). Its effec- tiveness was demonstrated on various psychological scales among cancer patients and cancer survivors. IBSR was also tested in a nonclinical population and it was shown to be effective in improving scales of depression and anxiety (Leufke, Zilcha-Mano, Feld, & Lev-Ari, 2013). A constant evaluation of current efforts and an examination of new efforts are required in order to maintain and develop mental well-being of teachers in the education system. System- atic and individual means must be combined in order to effectively treat exhaustion problems among teachers, with emphasis on mental health promotion (Flook, Goldberg, Pinger, Bonus, & Davidson, 2013). IBSR is classified as a meditation technique based on mindfulness and is there- fore applied as a mental well-being promotion technique. However, to the best of our knowledge, its effectiveness has not been tested among teachers in particular (Leufke et al., 2013). We hypothesized that IBSR has the potential of reducing exhaustion levels and increasing well-being levels among teachers. This would be consistent with the benefits seen from other types of mindfulness programs.

METHODS

Recruitment and Participants The current study is the qualitative part of a controlled trial designed to statistically and qualitatively assess the effects of IBSR on burnout and well-being levels among teachers. The study was carried out at a high school in a large city in Israel. All the teachers on its staff were eligible to participate in the study if they agreed to sign an informed consent form and had no previous experience with the IBSR technique. The study was carried out with the support of the school prin- cipal and was approved by the Israeli Ministry of Education (MOE).

An advertisement for recruiting teachers to participate in the study was published on the teachers’ billboard (at school and online). In addition, the invitation was announced dur- ing a teachers’ meeting. Teachers who were willing to par- ticipate met the main researcher at the school and were informed about study objectives and procedures. The first 27 teachers to sign the consent form were included in the 12-week IBSR intervention group in order to ensure a full group. The rest of the teachers (n = 27) were included in the control group. To reduce dropout rates from the control group, those who continued through until the end were told they would receive an IBSR kit (a book and a CD) at the end of the study. The assignment procedure was fully detailed in the advertisement.

The intervention arm (n = 27) included two groups who met on different days of the week. All the participants (n = 54) completed four psychological questionnaires before and after the intervention. Before the intervention, all partic- ipants of one of the intervention groups (n = 11) were con- tacted by telephone and were informed about the qualitative part of the research. All of those teachers agreed to partici- pate. This led to a smaller sample appropriate for the analysis method chosen for this research (interpretive phenomeno- logical analysis; Smith & Osborn, 2003) as a relatively small sample size of between 6 and 12 is sufficient to arrive at conclusions (Baker & Edwards, 2014). Two teachers did not participate in the first interview due to a busy schedule and one teacher joined the intervention group one day before the beginning of the workshop, leaving insufficient time to complete the interview. A third teacher did not complete the second interview due to a busy schedule. The total number of subjects who completed all components of the qualitative study were eight.

The participants of this study, all high school teachers in the same school, held different positions. The smaller sample is shown in Table 1.

Intervention Method The first stage of the IBSR technique is to systematically identify the thoughts that cause stress and suffering, and to record the specific thoughts about various stressful sit- uations by using the Judge Your Neighbor worksheet (see the appendix). The next stage is an inquiry of the stressful thoughts by a series of questions and turnarounds. Partici- pants choose the main thoughts they had written down on the worksheet and investigate them by four guided ques- tions: (1) Is it true? (2) Can I absolutely know that it is true? (3) How do I react when I believe that thought? (4) Who would I be without the thought? This self-investigation enables the individuals to examine their emotional and phys- ical responses during stressful situations. This stage is med- itative, and the participants are guided to be in a state of witnessing awareness, in which they observe the thoughts that come into mind without trying to control or direct them (Katie & Mitchell, 2003). In the turnarounds, the participants experience a revised interpretation of reality. For example, if the original thought was “My pupils don’t like me,” possi- ble turnarounds can be “I don’t like my pupils” (turnaround to the other), “I don’t like myself” (turnaround to myself ), or “My pupils do like me” (turnaround to the opposite). The par- ticipants are guided to find three genuine examples in which the turnaround is as true as the original thought. By doing so, they can understand that they do not have to automati- cally believe the stressful thoughts, but can choose different interpretations of reality (Katie & Mitchell, 2003).

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Table 1 Sample Group

Pseudonym Age Educational field Years of experience Interviews completed

(Before and after the intervention)

Rosette 48 Math, special education homeroom teacher 7 Before + After Hen 45 English 12 Before + After Yehudit 56 English 15 Before + After Tamar 40 Arabic 10 After Yaela 42 Physics 8 Before + After Keren 45 Literature, homeroom teacher 18 Before + After Ricky 42 Drama 11 Before + After Paula 38 History, homeroom teacher 13 Before + After Shira 44 English, homeroom teacher 9 Before + After Neriya 35 Bible teacher 6 Before Shaked 39 Educational counselor 10 Before

The IBSR intervention lasted 12 weeks and included weekly group meetings (3.5 hr/meeting) and weekly indi- vidual sessions with a facilitator by telephone (1 hr/session). All the sessions were standardized according to a train- ing manual, and each session was assessed afterwards for maintaining consistency during the program. The workshop was adapted specifically to homeroom teachers. The group forum training was designed to address teaching-related issues, such as self-esteem as a teacher, the student–teacher relationship, work under noise and pressure, professional development, and others. More personal issues were addressed in the individual sessions on the telephone with the facilitators. Participants were included in the final study analysis if they had been present in at least 75% of the group meetings and completed 50% of the home practice. All of the participants complied with these basic terms.

Data Collection The data were collected from semi-structured interviews which were conducted during the 2 weeks before and after the intervention, and each interview lasted for 1 hr. The goal of a semi-structured interview is to create an open dialogue between the interviewer and the interviewee, and to pro- vide the opportunity for people to tell their story openly and freely with minimal interference (Smith & Osborn, 2003). At the first interview, the participants were asked the follow- ing questions: “Can you describe your everyday experiences at school? What is your main motivation in teaching? What is important for you? What are your main difficulties? How do you cope with them?” In order to estimate their expec- tations from the workshop, they were also asked: “What benefits do you wish to achieve from the intervention?” At the second interview, they were asked to describe their gen- eral impressions: “Please tell me about your experience in the workshop.” Elaboration or clarification was requested as

needed. The interviews were conducted and recorded by one of the researchers. The recordings were then transcribed by an objective third party who issued the textual interviews used in the research while ensuring that personal informa- tion remained confidential.

Data Analysis The interviews were analyzed using the interpretative phe- nomenological analysis method (Smith & Osborn, 2003). This method aims to investigate people’s experiences from a subjective point of view, while emphasizing the way they make sense of their personal and social world. It includes several phases. In the first phase of this study’s analysis, two of the researchers (the interviewer and the medical psychol- ogist) interpreted the transcripts. Each transcript was care- fully read several times, significant topics were marked, and attention was focused on language and the use of key words or metaphors. In the next phase, the main topics of each interview were identified and conceptualized into themes, as expressed by specific phrases that aimed to reflect the mean- ing of the text. Analytical or theoretical connections between the themes composed the superordinate themes.

RESULTS

The results of the analysis show the interview data provide a rich description of teachers’ reflections about the effects of the 12-week IBSR intervention on the individual teacher with an emphasis on the development of subsequent abili- ties to cope with the unique challenges of their profession. The results are separated into three parts: (1) themes that were revealed before the intervention; (2) themes that were revealed after the intervention; (3) the limitation of the work- shop, as described by some of the participants. Parts 1 and 2 consider the description of the psychological state and

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the outcome behaviors of the participants in the classroom, in the school environment and at home, and provide some interpretation based on other published literature.

Main Themes: Abstract Before the intervention, the teachers described multiple social interactions as being part of their daily routine. Despite the positive and supportive relations with their colleagues, they also described an emotional overload and difficulty in dealing with the complicated reality. Moreover, they expressed a sense of frustration due to their unful- filled expectations and the gap between their professional ideology and the daily reality. After practicing the IBSR, teachers described two main experiences—a more centered and focused self and a greater ability to accept reality. The workshop’s structured and systematic format was suitable in this context, and it was described by them as being highly beneficial. Details of teachers’ responses—before, during, and after the intervention— are presented in three separate panels over the next few pages.

Pre-Intervention Interview Results Analysis of the interview data collected prior to delivery of the intervention revealed two superordinate themes, as described in Figure 1. They represent the complex and stressful dynamic of the profession as detailed by the teachers. The participants’ names and data remained confidential.

Multiple Relationships The teachers described various interactions and dynamics as part of their daily work routine with colleagues, pupils, and the pupils’ parents. These relationships were described as personal and having an emotional involvement, rather than professional. Relations with colleagues and school management: support and understanding. Paula “There are a couple of teachers, who are much more than friends. … it’s relaxing, it helps. … You are not

alone.” Rosette “We have a great staff, supportive. … Advice from a colleague is worth a lot … the cooperation is great.” Yehudit “She (the principal) is very nice. … I can always tell her how I feel.” Yaela “The principal and the staff are great and supportive … it feels like a family.” Interactions with pupils and parents were usually described as highly demanding and intensive, with considerable emotional

involvement that made it challenging to set clear boundaries. Yehudit “Spoiled kids … unable to postpone gratification … unable to deal with difficulties. … Sometimes

parents tell you, teach him, that is your job. … I tell them let’s do it together, I can’t do it without you.” Tamar “I beg them to stop disrupting the class. … it is very difficult. … I sometimes tell them to please be quiet,

I want to speak … that is so insulting. … I teach them properly, they are always ready for tests … but sometimes it is very difficult to control them.”

Ricki “I constantly cope with boundaries issues … pupils text me during weekends and holidays … it’s difficult for me to set any boundaries. … There is a conflict between the need to be available for them and the need to be with my family.”

Keren “If a parent calls you in the evening, how can you not answer him!? I cannot do that, it concerns children, not computers and papers. I had pupils who tried to commit suicide. Others ran away from home … how can I ignore that!?”

Rosette “I need to work harder on setting boundaries … they are not so clear … I need to be more assertive.”

Fig. 1. Main themes before and after the IBSR intervention.

After the intervention, the teachers detailed various tech- nical aspects about the workshop that enable them to expe- rience the emotional process, such as the group format and the weekly phones calls with the facilitators. They all emphasized the importance of the practical tools given to them during the workshop (e.g., the “three types of business,” the four questions). Given the teachers’ compli- cated and chaotic experiences and their lack of emotional resources, their need for a systematic and focused practice is understandable:

The intervention was very systematic from the beginning. … It is a systematic process, which repeats itself. … I like it a lot. (Shira) Very clear rules were set, and suddenly you realize it works if you are consistent. (Paula)

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Expectations vs. Reality Positive attitude toward the profession was noted by most of the teachers. This included ideological reasons for choosing this profession

and a positive perception regarding a teacher’s contribution and role. Rosette “Teaching is a way of life. It’s a great privilege. … The pupils’ success is our success. … It’s like therapy, you touch people’s lives.” Hen “I wanted to pass on my knowledge. … It’s a childhood dream. I had a geography teacher, whom I appreciated a lot, the way she

taught, her caring and interest.” Yehudit “Each teacher is an educator. … Not just preparing pupils to the final exams. … You need empathy, love for children. …

Understanding their uniqueness. … They will learn only if you create a personal contract with them.” Overload: Their daily routine as teachers was described as highly demanding and stressful. Yaela “There is a lot of stress, many things to do … How can I function with all these tasks?!” Keren “When you enter the class you have to be focused. … with 40 pupils. … You have to be extra-focused and concentrated, to

ignore your personal problems. … You always have stuff on your mind. … You don’t rest even at home. … No rest.” Paula “You need a lot of energy. … You work many hours and it is natural to be burned out. … The work is very difficult. … A

stranger won’t understand it. … All my friends have nine-to-five desk jobs. The only noise they hear is the air conditioner … while I haven’t eaten anything the whole day.”

Frustration: The busy schedule, full of tasks and commitments, limited their ability to deal with the meaningful educational issues. This gap between their ideology and personal expectations vs. their daily routine was experienced as a source of frustration and exhaustion.

Hen “I have many ideas … but it is difficult to accomplish them. … Time is so limited. … I start my day, from one lesson to the other. … I hardly have time to go to the bathroom. … There is so little energy available for new ideas … you can accomplish only 10 percent of them.”

Ricki “All the bureaucracy. … I don’t do what I am supposed to do. … I am working so hard … I am exhausted … they expect me to achieve goals.”

Keren “I was very motivated … I did so many things. … (Now) I wake up every morning and I don’t want to go to work. … I wish the day will be over as quickly as possible.”

Yehudit “I don’t want things to concern me … to affect me. … I want to deal with my own business and not to get hurt … it will make things much easier for me.”

After the Intervention After the workshop, two super ordinate themes emerged, which represented a more focused and structured perspective toward their

profession and its unique aspects, as described by the teachers (Figure 1), accepting reality and centeredness. Accepting reality—increased awareness:—The teachers described an increased awareness of their reactions and perceptions of reality.

This awareness helped them accept reality as is and avoid futile attempts to change or confront it, thereby reducing their level of frustration and stress. The teachers experienced a higher level of satisfaction with themselves as well as with their surroundings.

Yaela “The workshop helped me to stop arguing with reality. … Today I truly understand how to love what exists and there is a lot to love! … The bad is always there, you just need to focus less on it … , when I don’t argue and accept myself … it is like going out of jail in some ways.”

Neriya “When [pupils] talk—I don’t immediately freak out. You know what I mean? Until now every little twit drove me crazy. But now I say it’s okay, it’s okay for them to talk, so what if they are talking, keep teaching.”

Shaked “The workshop helped me to focus my awareness on various situations … not to automatically complain but to understand when there is a genuine pain that I need to work on so it won’t hurt anymore … for example, when it is difficult for my children, it hurts me physically … so I tell myself that I need to think about the situation differently.”

Shira “It [the intervention] confirmed that I am on the right track and that is important. … In the complexity of teaching, you need to adjust yourself … it confirmed that my instincts are correct.”

Hen “One thought terribly bothered me. I sat down and devoted some time to it. I actually took the ‘Judge Your Neighbor’ sheet and applied The Work. Things I’m familiar with, I use the turnarounds on. Others which I’m not, like when I’m in a midday overload, I tell myself to pay attention to bad feelings and take them on an inquiry.”

Accepting reality—flexible thinking The participants described their improved ability to interpret and perceive various situations in a more flexible manner, with no rigid assumptions or emotional involvement. This was achieved mainly by the technique of the turnaround, which enabled the participants to acknowledge the subjectivity of their thoughts and beliefs.

Shaked “Many times during stress … we have a thought that causes us to get stuck and it (the turnarounds) was very easy. … Now I turn the situation to myself or to the other, and it releases something in your way of thinking … it is important for me that the house will be clean, so my son does not have to do the dishes. … It changed the way I act in my house, with my children and with my husband.”

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Yehudit “I understand that children are sitting in front of me in the classroom, not adults … and so my expectations should be different. … I don’t need to judge them according to my values; they are in a different place than me, so I need to treat them differently.”

Paula “Mainly doubting your thoughts, instead of blaming someone else. Asking the questions, and the turnarounds, creates doubts and takes you elsewhere. Neutralizes all kinds of variables: when you are in the middle of a storm, you are certain it is intentional and devious, and then when you turn it around, you realize—wait, I contribute to this situation as well!”

Centeredness: The teachers described a more focused and centered self, which helped them to deal better with the various relationships and dynamics in their daily routine. This experience was different from the former experience of splits and complexity, which was described by them before the intervention. During the workshop they were trained to set emotional boundaries in various daily interactions, in particular, the technique of “the three types of businesses,” which was described as highly practical and helpful.

Ricki “We checked whose ‘business’ were they, and it was clear that they were the pupil’s. … I was frustrated that I cannot help her, but another teacher helped me understand that I am dealing with her business. … I could not help her because I was too emotionally involved … setting boundaries was what she needed the most.”

Rosette “For me it was a problem that lasted for years … and then things surfaced here during the workshop. Being very clear, set boundaries, speak assertively. I left with a large toolbox. Sometimes I feel we are kind of slaves of our thoughts. … ”

Yehudit “It really changed the way I act in the classroom … my pupils’ behavior affects me much less, which is a significant benefit for me. … I respond less to their behavior … emotionally. … Once if there was noise, if they didn’t listen … I used to get so upset and scream. … Now I don’t get nervous and aggressive. … Three months ago, I was crazy, bitter, nervous. … I used to react very intuitively … very aggressively. … Now I take my time. … I am more relaxed and I think. … I explore it my way.”

Yaela “The thing that affected me the most was the issue of the ‘business.’ … Many times you discover you are not dealing with your own ‘business.’ … You deal with those of others and you neglect your own. … This workshop can help teachers to avoid misunderstandings with pupils … to reduce conflicts … using the four simple questions we learned. … Investigating our thoughts as teachers can reduce stressful situations in teaching. … I am much more attentive, I try to understand what the other person wants.”

Limitations of the Workshop Although the teachers were satisfied with the intervention, they described several limitations of the workshop. First, most of them were skeptical about their ability to practice the technique without regular group meetings. They expressed a need to integrate it into their routine. Second, some teachers were concerned about the exposure of personal issues in front of their colleagues, with whom they have an ongoing professional relationship.

DISCUSSION

Before the intervention, the interviews revealed a state of emotional overload and exhaustion among the participants. This finding was described in previous studies as a charac- teristic of teaching and as a source of emotional stress for teachers (Sorek et al., 2004). A study by Friedman (2000) demonstrated that unaccomplished expectations and shat- tered dreams have a significant role in the process of burnout among teachers. After the intervention, the positive effects described above can be evaluated by the theoretical frame- work of psychological well-being (Keyes, 2007; Ryff, 1989, 1995; Sin & Lyubomirsky, 2009; Tylee & Wallace, 2009; World Health Organization, 2004). This model includes six dimensions of wellness, manifested in the results of the study as follows. (1) Self-acceptance, demonstrated in the current study by the teachers having reported higher levels of self-awareness and a more peaceful inner self

after the intervention, as well as by acknowledging their abilities as well as accepting their weaknesses. (2) positive and reciprocal relationships with others, expressed as the capability of empathy, affection, and intimacy. The teach- ers described better interactions with their surroundings after the intervention due to their enhanced ability to set boundaries with less emotional involvement and by hav- ing a more flexible attitude. In addition, the positive and close relationships that were formed with the rest of the participants helped the teachers to feel more acknowledged and appreciated, which improved their daily interactions at work. (3) Autonomy in thoughts and action, demon- strated by the ability to resist social pressure and to regulate behavior and thoughts by personal standards. The improved ability to set boundaries and sustain centered, self-helped teachers maintain their personal standards and values with less pressure from external surroundings. (4) Environmental mastery and competence, which translated into the ability to manage complex external surroundings and to choose or create contexts suitable to personal needs and values. The teachers’ increased ability to set boundaries with a more flexible position improved their ability to perform in the classroom and handle interpersonal dynamics. (5) Purpose in life, which replaced ideology and meaning as significant and inherent features of their profession by personal values and goals, and redefined them as a current resource of meaning and fulfillment. (6) Personal growth and development, as defined by feelings of realizing one’s

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IBSR Meditation for Burnout Among Teachers

potential and openness to new experiences. The meditative process of the intervention focused on personal aspects and helped the teachers to acknowledge their abilities and inner strength, thereby initiating a process of personal development.

Limitations of the Study We are aware of several limitations of this study. The partici- pants were all from a single high school in Israel. It evaluated only the short-term effects of a short mindfulness interven- tion. The data were collected by conducting two personal interviews with the researcher, which may have had an addi- tional effect on the participants’ responses. It included only one IBSR group from the two intervention groups. How- ever, the group was selected randomly which minimizes the risk of bias. In addition, as described in the Results section, the teachers themselves described several limitations of the workshop, such as the need for regular practice as an integral part of their work and their ambivalence about its implemen- tation in a professional setting with colleagues.

To conclude, the current qualitative study demonstrated the positive effects of the IBSR intervention on unique aspects related to teaching. These results should be fur- ther evaluated in large-scale studies with longer follow-ups in order to widen the understanding of the technique’s potential efficacy as a tool for improving well-being among teachers.

Acknowledgment—We thank Esther Eshkol for editorial assistance.

In Week 2 we examined items that can prevent you from reaching your goals and we discussed how to avoid procrastination and set priorities. This week, we explore how to set goals and look at impacts of stress in our lives. Your readings will cover SMART goal setting, overcoming obstacles, and stress management. 

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In Week 2 we examined items that can prevent you from reaching your goals and we discussed how to avoid procrastination and set priorities. This week, we explore how to set goals and look at impacts of stress in our lives. Your readings will cover SMART goal setting, overcoming obstacles, and stress management.

Before responding to the discussion, consider your own goals and the obstacles or stressors that you may face.

Respond to the following in a minimum of 175 words:

  • How would you describe the benefits of creating SMART goals to a recent high-school graduate who is about to start college?
  • Reflect on one of your own personal, academic,or professional goals. Which of the SMART components might need to be revisited, and why?
  • One obstacle to achieving our goals is stress. What are some of your current stressors? What strategies or coping skills can you use to address that source of stress?

Are emotions determined by nature and pre programmed biologically, are in infant’s emotions development through stimulation and conditioning, or do you believe it is a combination of the two?

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1. Are emotions determined by nature and pre programmed biologically, are in infant’s emotions development through stimulation and conditioning, or do you believe it is a combination of the two?

2. What emotions cause behavior of smiling? Write at least one paragraph explaining the possible antecedents of the emotions.

3. What emotions cause the behavior of crying? Write at least one paragraph explaining the possible antecedents of the emotions.

4. Do you believe that newborns can visually recognize an individual’s face? How might intermodal perception be related to this? Describe any research which has been conducted, that might help support the answer. (Please list reference info in APA Style and cite within the answer) (Must use at least 2 references)

*** Please make sure to number the section as you answer each question.***

Researchers Owens, Belon, & Moss (2010) wanted to investigate the impact of school start time on the sleep patterns of adolescents.

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  1. Researchers Owens, Belon, & Moss (2010) wanted to investigate the impact of school start time on the sleep patterns of adolescents. They studied teenagers who were enrolled in an American high school, both before (fall semester) and after (spring semester) the entire school had decided to shift its start time from 8:00 am to 8:30 am. Students completed a survey asking what time they went to bed the night before, how many hours of sleep they’d gotten, and their daytime sleepiness and level of depressed mood. The researchers found that after the 8:30 start time was implemented, students reported getting 45 minutes more sleep each night, and the percentage of students who reported more than 8 hours per night jumped from 16.4% to 54.7%. In addition, students’ level of daytime sleepiness and depressed mood decreased after the 8:30 start time began.
    1. Is this study a nonequivalent control group design, a nonequivalent control group pretest/posttest design, an interrupted time-series design, or a nonequivalent control group interrupted time-series design?
    2. Graph the results of the study, according to the results in the description. (There are multiple dependent variables; choose only one to graph).
    3. What causal statement might the researchers be trying to make, if any? Is it appropriate? Use the results and design to interrogate the study’s internal validity
    4. If you notice any internal validity flaws, can you redesign the study to remove the flaw?
    5. Ask one question to address construct validity and one to address external validity.

Write a 1,000-1,250-word essay outlining all six guidelines for effectively challenging a client

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Write a 1,000-1,250-word essay outlining all six guidelines for effectively challenging a client. For each guideline, provide a case example illustrating the principle. Address the following in your paper: How can counselors challenge a client without getting into a power struggle with a client, or provoking client defensiveness? How can counselors help a client to identify unused resources and strengths? How can counselors help a client to identify blind spots while continuing to provide empathy and support for the client? How would counselors work with a client within an interdisciplinary treatment team? How can a counselor act as a consultant when a practicing counselor asks for help to strengthen their challenging skills with clients? For this part of the assignment, you may write in the first person. Reflect on your level of assertiveness. Do you feel you are assertive enough to challenge clients comfortably or do you feel you are too passive or aggressive? What might keep you from challenging a client? Provide at least three scholarly references in your paper. Prepare this assignment according to the guidelines found in the APA Style Guide

Psychoanalytic and Humanistic/Existential

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The Final Paper provides the opportunity for you to demonstrate your ability to do research and apply the concepts. This assignment MUST be typed, double-spaced, in APA style, and must be written at graduate level English. You are required to utilize the Internet and the University Virtual Library to research current literature and information to enhance your analysis for this project.

Using the University Virtual Library, find articles from professional journal dated within the past 5 years. A minimum of eight (8) research articles are required to complete this assignment.

Directions:

For the final research paper you will be comparing and contrasting 2 schools of counseling and psychotherapy.

For example:

Psychoanalytic and Humanistic/Existential
Psychoanalytic and Cognitive Behavioral
Psychoanalytic and Family Systems Approach
Cognitive Behavioral and Humanistic/Existential
Cognitive Behavioral and Family Systems
Etc.

If you are not sure if you are choosing 2 different schools of counseling, please write your mentor prior to doing the research paper.

Your research paper must include:

·        –  compare and contrast both theories

·         – discuss evidence-based research on applicability of each theory and treatment

·         – present research on the pros and cons of each theory to specific populations

·        –  integrate research on culture and diversity in regard to the applicability of each theory

·         – create an original case example that ties in your research (this should only be ½ to 1 page)

Your final paper should be 8-10 pages plus a title and reference page

Behaviorally Defined Symptoms: Rita attempts to control her weight by fasting or consuming large quantities of food

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PSY650 Week Three Treatment Plan

 

 

Behaviorally Defined Symptoms: Rita attempts to control her weight by fasting or consuming large

quantities of food (e.g., multiple slices of pizza, gallons of ice cream) followed by purging (vomiting).

Rita binges two to three times per week, and reports feeling “guilty” after each episode.

 

Diagnostic Impression: Bulimia Nervosa

 

Long-Term Goal: Reduce bingeing and compensatory behaviors by changing distorted attitudes about

weight and any other thinking patterns.

Short-Term Goal: Establish regular eating patterns by eating in regular intervals and consuming 2,000

calories per day.

 

Intervention 1: Dr. Heston will educate Rita about the etiology of eating disorders.

Intervention 2: Rita will read psychoeducational handouts and treatment manuals for homework.

Intervention 3: Rita will monitor her food consumption using a nutritional journal.

Intervention 4: Dr. Heston will teach Rita how to identify dysfunctional thinking and develop

more healthy cognitions and coping skills.

 

For additional information regarding Rita’s case history and the outcome of the treatment interventions,

please see Dr. Heston’s session notes under Case 9 in Gorenstein and Comer’s (2015), Case Studies in

Abnormal Psychology.

Treatment Plan  and Case

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See the PSY650 Week Three Treatment Plan  and Case 9: Bulimia Nervosa in Gorenstein and Comer (2014), 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 all attached. Assess the evidence-based practices implemented in this case study(1)Explain the connection between each theoretical orientation used by Dr. Heston and the treatment intervention plans utilized in the case(2)Describe the cognitive-behavioral model of the maintenance of bulimia nervosa(3)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(4)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(5)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(6)Evaluate the effectiveness of the treatment interventions implemented by Dr. Heston, supporting your statements with information from the case from the articles titled intervention attached(7)Recommend three additional treatment interventions that would be appropriate in this case. The recommended articles attached may be useful in generating your response to this criterion. Justify your selections with information from the case?

CASE 18 You Decide: The Case of Julia

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CASE 18 You Decide: The Case of Julia

This case is presented in the voices of Julia and her roommate, Rebecca. Throughout the case, you are asked to consider a number of issues and to arrive at various decisions, including diagnostic and treatment decisions. Appendix A lists Julia’s probable diagnosis, the DSM-5 criteria, clinical information, and possible treatment directions.

Julia Measuring Up

I grew up in a northeastern suburban town, and I’ve lived in the same house for my entire life. My father is a lawyer, and my mother is the assistant principal at our town’s high school. My sister, Holly, is 4 years younger than I am. My parents have been married for almost 20 years. Aside from the usual sort of disagreements, they get along well. In fact, I would say that my entire family gets along well. We’re not particularly touchy-feely: It’s always a little awkward when we have to hug our grandparents on holidays, because we just never do that sort of thing at home. That’s not to say that my parents are uninterested or don’t care about us. Far from it; even though they both have busy work schedules, one of them would almost always make it to my track and cross-country meets and to Holly’s soccer games. My mother, in particular, has always tried to keep on top of what’s going on in our lives. In high school, I took advanced-level classes and earned good grades. I also got along quite well with my teachers, and ended up graduating in the top 10 percent of my class. I know this made my mother really proud, especially since she works at the school. She would get worried that I might not be doing my best and “working to my full potential.” All through high school, she tried to keep on top of my homework assignments and test schedules. She liked to look over my work before I turned it in, and would make sure that I left myself plenty of time to study for tests.

Describe the family dynamics and school pressures experienced by Julia. Under what circumstances might such family and school factors become problematic or set the stage for psychological problems?

In addition to schoolwork, the track and cross-country teams were a big part of high school for me. I started running in junior high school because my parents wanted me to do something athletic and I was never coordinated enough to be good at sports like soccer. I was always a little bit chubby when I was a kid. I don’t know if I was actually overweight, but everyone used to tease me about my baby fat. Running seemed like a good way to lose that extra weight; it was hard at first, but I gradually got better and by high school I was one of the best runners on the team. Schoolwork and running didn’t leave me much time for anything else. I got along fine with the other kids at school, but I basically hung out with just a few close friends. When I was younger, I used to get teased for being a Goody Two-Shoes, but that had died down by high school. I can’t remember anyone with whom I ever had problems. I did go to the prom, but I didn’t date very much in high school. My parents didn’t like me hanging out with boys unless it was in a group. Besides, the guys I had crushes on were never the ones who asked me out. So any free time was mostly spent with my close girlfriends. We would go shopping or to the movies, and we frequently spent the night at one another’s houses. It was annoying that although I never did anything wrong, I had the earliest curfew of my friends. Also, I was the only one whose parents would text me throughout the night just to check in. I don’t ever remember lying to them about what I was doing or who I was with. Although I felt like they didn’t trust me, I guess they were just worried and wanted to be sure that I was safe.

 

 

Julia Coping With Stress

Now I am 17 years old and in the spring semester of my first year at college. I was awarded a scholar-athlete full scholarship at the state university. I’m not sure of the exact cause of my current problems, but I know a lot of it must have to do with college life. I have never felt so much pressure before. Because my scholarship depends both on my running and on my maintaining a 3.6 grade point average, I’ve been stressed out much of the time. Academic work was never a problem for me in the past, but there’s just so much more expected of you in college. It was pressure from my coach, my teammates, and myself that first led me to dieting. During the first semester, almost all my girlfriends in college experienced the “freshman 15” weight gain—it was a common joke among everyone when we were up late studying and someone ordered a pizza. For some of them it didn’t really matter if they gained any weight, but for me it did. I was having trouble keeping up during cross-country practices. I even had to drop out of a couple of races because I felt so awful and out of shape. I couldn’t catch my breath and I’d get terrible cramps. And my times for the races that I did finish were much worse than my high school times had been. I know that my coach was really disappointed in me. He called me aside about a month into the season. He wanted to know what I was eating, and he told me the weight I had gained was undoubtedly hurting my performance. He said that I should cut out snacks and sweets of any kind, and stick to things like salads to help me lose the extra pounds and get back into shape. He also recommended some additional workouts. I was all for a diet—I hated that my clothes were getting snug. In addition, I was feeling left out of the rest of the team. As a freshman, I didn’t know any of the other runners, and I certainly wasn’t proving myself worthy of being on the team. At that point, I was 5′6″ and weighed 145 pounds. When I started college I had weighed 130 pounds. Both of these weights fell into the “normal” body mass index range of 18.5 to 25, but 145 pounds was on the upper end of normal. Was the advice from Julia’s coach out of line, or was it her overreaction to his suggestions that caused later problems?

Dieting was surprisingly easy. The dining hall food bordered on inedible anyway, so I didn’t mind sticking to salads, cereal, or yogurt. Occasionally I’d allow myself pasta, but only without sauce. I completely eliminated dessert, except for fruit on occasion. If anyone commented on my small meals, I just told them that I was in training and gearing up for the big meets at the end of the season. I found ways to ignore the urge to snack between meals or late at night when I was studying. I’d go for a quick run, check Facebook and Twitter, take a nap—whatever it took to distract myself. Sometimes I’d drink water or Diet Coke and, if absolutely necessary, I’d munch on a carrot. Many eating disorders follow a period of intense dieting. Is dieting inevitably destructive? Are there safeguards that can be taken during dieting that can head off the development of an eating disorder?

Once I started dieting, the incentives to continue were everywhere. My race times improved, so my coach was pleased. I felt more a part of the team and less like an outsider. My clothes were no longer snug; and when they saw me at my meets my parents said I looked great. I even received an invitation to a party given by a fraternity that only invited the most attractive first- year women. After about a month, I was back to my normal weight of 130 pounds. At first, my plan was to get back down to 130 pounds, but it happened so quickly that I didn’t have time to figure out how to change my diet to include some of the things that I had been leaving out. Things were going so well that I figured it couldn’t hurt to stick to the diet a little longer. I was on a roll. I remembered all the people who I had seen on television who couldn’t lose weight even after years of trying. I began to think of my frequent hunger pangs as badges of honor, symbols of my ability to control my bodily urges. I set a new weight goal of 115 pounds. I figured if I hit the gym more often and skipped breakfast altogether, it wouldn’t be hard to reach that weight in another month or so. Of course

 

 

this made me even hungrier by lunchtime, but I didn’t want to increase my lunch size. I found it easiest to pace myself with something like crackers. I would break them into several pieces and only allow myself to eat one piece every 15 minutes. The few times I did this in the dining hall with friends I got weird looks and comments. I finally started eating lunch alone in my room. I would simply say that I had some readings or a paper to finish before afternoon class. I also made excuses to skip dinner with people. I’d tell my friends that I was eating with my teammates, and tell my teammates that I was meeting my roommate. Then I’d go to a dining hall on the far side of campus that was usually empty, and eat by myself. I remember worrying about how I would handle Thanksgiving. Holidays are a big deal in my family. We get together with my aunts and uncles and grandparents, and of course there is a huge meal. I couldn’t bear the stress of being expected to eat such fattening foods. I felt sick just thinking about the stuffing, gravy, and pies for dessert. I told my mother that there was a team Thanksgiving dinner for those who lived too far away to go home. That much was true, but then I lied and told her that the coach thought it would be good for team morale if we all attended. I know it disappointed her, but I couldn’t deal with trying to stick to my diet with my family all around me, nagging me to eat more.

Julia Spiraling Downward

I couldn’t believe it when the scale said I was down to 115 pounds. I still felt that I had excess weight to lose. Some of my friends were beginning to mention that I was actually looking too thin, as if that’s possible. I wasn’t sure what they meant—I was still feeling chubby when they said I was too skinny. I didn’t know who was right, but either way I didn’t want people seeing my body. I began dressing in baggy clothes that would hide my physique. I thought about the overweight people my friends and I had snickered about in the past. I couldn’t bear the thought of anyone doing that to me. In addition, even though I was running my best times ever, I knew there was still room there for improvement.

Look back at Case 9, Bulimia Nervosa. How are Julia’s symptoms similar to those of the individual in that case? How are her symptoms different?

Around this time, I started to get really stressed about my schoolwork. I had been managing to keep up throughout the semester, but your final grade basically comes down to the final exam. It was never like this in high school, when you could get an A just by turning in all your homework assignments. I felt unbearably tense leading up to exams. I kept replaying scenarios of opening the test booklet and not being able to answer a single question. I studied nonstop. I brought notes with me to the gym to read on the treadmill, and I wasn’t sleeping more than an hour or two at night. Even though I was exhausted, I knew I had to keep studying. I found it really hard to be around other people. Listening to my friends talk about their exam schedules only made me more frantic. I had to get back to my own studying. The cross-country season was over, so my workouts had become less intense. Instead of practicing with the team, we were expected to create our own workout schedule. Constant studying left me little time for the amount of exercise I was used to. Yet I was afraid that cutting back on my workouts would cause me to gain weight. It seemed logical that if I couldn’t keep up with my exercise, I should eat less in order to continue to lose weight. I carried several cans of Diet Coke with me to the library. Hourly trips to the lounge for coffee were the only study breaks I allowed myself. Aside from that, I might have a bran muffin or a few celery sticks, but that would be it for the day. Difficult though it was, this regimen worked out well for me. I did fine on my exams. This was what worked for me. At that point, I weighed 103 pounds and my body mass index was 16.6.

Based on your reading of either the DSM-5 or a textbook, what disorder might Julia be displaying? Which of her symptoms suggest this diagnosis?

 

 

After finals, I went home for winter break for about a month. It was strange to be back home with my parents after living on my own for the semester. I had established new routines for myself and I didn’t like having to answer to anyone else about them. Right away, my mother started in; she thought I spent too much time at the gym every day and that I wasn’t eating enough. When I told her that I was doing the same thing as everyone else on the team, she actually called my coach and told him that she was concerned about his training policies! More than once she commented that I looked too thin, like I was a walking skeleton. She tried to get me to go to a doctor, but I refused. Dinner at home was the worst. My mother wasn’t satisfied when I only wanted a salad—she’d insist that I have a ‘’well-balanced meal” that included some protein and carbohydrates. We had so many arguments about what I would and wouldn’t eat that I started avoiding dinnertime altogether. I’d say that I was going to eat at a friend’s house or at the mall. When I was at home I felt like my mother was watching my every move. Although I was worried about the upcoming semester and indoor track season, I was actually looking forward to getting away from my parents. I just wanted to be left alone—to have some privacy and not be criticized for working out to keep in shape.

Was there a better way for Julia’s mother to intervene? Or would any intervention have brought similar results?

Since I’ve returned to school, I’ve vowed to do a better job of keeping on top of my classes. I don’t want to let things pile up for finals again. With my practice and meet schedule, I realize that the only way to devote more time to my schoolwork is to cut back on socializing with friends. So, I haven’t seen much of my friends this semester. I don’t go to meals at all anymore; I grab coffee or a soda and drink it on my way to class. I’ve stopped going out on the weekends as well. I barely even see my roommate. She’s asleep when I get back late from studying at the library, and I usually get up before her to go for a morning run. Part of me misses hanging out with my friends, but they had started bugging me about not eating enough. I’d rather not see them than have to listen to that and defend myself. Even though I’m running great and I’m finally able to stick to a diet, everyone thinks I’m not taking good enough care of myself. I know that my mother has called my coach and my roommate. She must have called the dean of student life, because that’s who got in touch with me and suggested that I go to the health center for an evaluation. I hate that my mother is going behind my back after I told her that everything was fine. I realize that I had a rough first semester, but everyone has trouble adjusting to college life. I’m doing my best to keep in control of my life, and I wish that I could be trusted to take care of myself. Julia seems to be the only person who is unaware that she has lost too much weight and developed a destructive pattern of eating. Why is she so unable to look at herself accurately and objectively?

Rebecca Losing a Roommate

When I first met Julia back in August, I thought we would get along great. She seemed a little shy but like she’d be fun once you got to know her better. She was really cool when we were moving into our room. Even though she arrived first, she waited for me so that we could divide up furniture and closet space together. Early on, a bunch of us in the dorm started hanging out together, and Julia would join us for meals or parties on the weekends. She’s pretty and lots of guys would hit on her, but she never seemed interested. The rest of us would sit around and gossip about guys we met and who liked who, but Julia just listened. From day one, Julia took her academics seriously. She was sort of an inspiration to the rest of us. Even though she was busy with practices and meets, she always had her readings done for class. But I know that Julia also worried constantly about her studies and her running. She’d talk about how frustrating it was to not be able to compete at track at the level she knew she was capable of. She would get really nervous before races. Sometimes she couldn’t sleep, and

 

 

I’d wake up in the middle of the night and see her pacing around the room. When she told me her coach suggested a new diet and training regimen, it sounded like a good idea. I guess I first realized that something was wrong when she started acting a lot less sociable. She stopped going out with us on weekends, and we almost never saw her in the dining hall anymore. A couple of times I even caught her eating by herself in a dining hall on the other side of campus. She explained that she had a lot of work to do and found that she could get some of it done while eating if she had meals alone. When I did see her eat, it was never anything besides vegetables. She’d take only a tiny portion and then she wouldn’t even finish it. She didn’t keep any food in the room except for cans of Diet Coke and a bag of baby carrots in the fridge. I also noticed that her clothes were starting to look baggy and hang off her. A couple of times I asked her if she was doing okay, but this only made her defensive. She claimed that she was running great, and since she didn’t seem sick, I figured that I was overreacting. Why was Rebecca inclined to overlook her initial suspicions about Julia’s behaviors? Was there a better way for the roommate to intervene?

I kept believing her until I returned from Thanksgiving. It was right before final exams, so everyone was pretty stressed out. Julia had been a hard worker before, but now she took things to new extremes. She dropped off the face of the earth. I almost never saw her, even though we shared a room. I’d get up around 8:00 or 9:00 in the morning, and she’d already be gone. When I went to bed around midnight, she still wasn’t back. Her side of the room was immaculate: bed made, books and notepads stacked neatly on her desk. When I did bump into her, she looked awful. She was way too thin, with dark circles under her eyes. She seemed like she had wasted away; her skin and hair were dull and dry. I was pretty sure that something was wrong, but I told myself that it must just be the stress of the upcoming finals. I figured that if there were a problem, her parents would notice it and do something about it over winter break. When we came back to campus in January, I was surprised to see that Julia looked even worse than during finals. When I asked her how her vacation was, she mumbled something about being sick of her mother and happy to be back at school. As the semester got under way, Julia further distanced herself from us. There were no more parties or hanging out at meals for her. She was acting the same way she had during finals, which made no sense because classes had barely gotten going. We were all worried, but none of us knew what to do. One time, Julia’s mother sent me a message on Facebook and asked me if I had noticed anything strange going on with Julia. I wasn’t sure what to write back. I felt guilty, like I was tattling on her, but I also realized that I was in over my head and that I needed to be honest. How might high schools and universities better identify individuals with serious eating disorders? What procedures or mechanisms has your school put into operation?

I wrote her mother about Julia’s odd eating habits, how she was exercising a lot and how she had gotten pretty antisocial. Her mother wrote me back and said she had spoken with their family doctor. Julia was extremely underweight, even though she still saw herself as chunky and was afraid of gaining weight. A few days later, Julia approached me. Apparently she had just met with one of the deans, who told her that she’d need to undergo an evaluation at the health center before she could continue practicing with the team. She asked me point-blank if I had been talking about her to anyone. I told her how her mother had contacted me and asked me if I had noticed any changes in her over the past several months, and how I honestly told her yes. She stormed out of the room and I haven’t seen her since. I know how important the team is to Julia, so I am assuming that she’ll be going to the health center soon. I hope that they’ll be able to convince her that she’s taken things too far, and that they can help her to get better.

How might the treatment approaches used in Cases 2, 4, and 9 be applied to Julia? How should they be altered to fit Julia’s problems and personality? Which aspects of these treatments would not be appropriate? Should additional interventions be applied?

 

 

Decide: The Case of Julia

The individual in Case 18: The Case of Julia would receive a diagnosis of anorexia nervosa. Dx Checklist   Anorexia Nervosa 1. Individual purposely takes in too little nourishment, resulting in body weight that is very low and below that of other people of similar age and gender. 2. Individual is very fearful of gaining weight, or repeatedly seeks to prevent weight gain despite low body weight. 3. Individual has a distorted body perception, places inappropriate emphasis on weight or shape in judgments of herself or himself, or fails to appreciate the serious implications of her or his low weight.

(Based on APA, 2013.)

Clinical Information 1. Research investigating risk factors for eating disorders have reliably identified body dissatisfaction as a significant factor in the future development of eating disorders. Some prospective studies have also found a history of depression and critical comments from teachers/coaches/siblings to be important predictors (Jacobi et al., 2011). Stice, Marti, and Durant (2011) identified two separate risk-factor pathways based on whether the individual experienced high levels of body dissatisfaction. For adolescent girls with high body dissatisfaction, their risk for developing an eating disorder was amplified by the presence of depressive symptoms. However, among girls with lower levels of body dissatisfaction, those reporting significant dieting behaviors were at the highest risk for developing a future eating disorder. 2. Individuals with anorexia typically struggle with comorbid conditions such as depression and/or anxiety disorders (Von Lojewski, Boyd, Abraham, & Russell, 2012). In addition, people with anorexia nervosa may experience low self-esteem, substance abuse, and clinical perfectionism (Cooper & Fairburn, 2011; Fairburn, Cooper, & Shafran, 2003). 3. Although anorexia nervosa can occur at any age, the peak age of onset is between 14 years and 18 years. 4. Prevalence: The lifetime prevalence estimates range from 0.5 percent to 3.5 percent. The DSM-5 reports the 12-month prevalence rate as 0.4 percent. Approximately 90 percent of all cases occur among females. 5. Surveys suggest that approximately 2 percent to 5 percent of female college athletes may suffer from an eating disorder (Greenleaf, Petrie, Carter, & Reel, 2009), with the highest rates among college gymnasts, swimmers, and divers (Anderson & Petrie, 2012). 6. The mothers of individuals with eating disorders are more likely to diet and have perfectionistic tendencies compared with mothers without a child with an eating disorder (Lombardo, Battagliese, Lucidi, & Frost, 2012; Mushquash & Sherry, 2013). 7. Anorexia nervosa has a particularly high mortality rate (up to 6 percent). A 20-year longitudinal study found that a long duration of illness, substance abuse, low weight status, and poor psychosocial functioning increased the risk for mortality among individuals with anorexia (Franko et al., 2013). Common Treatment Strategies The following treatment strategies are based on “enhanced” cognitive-behavioral therapy (CBT- E) proposed by Fairburn and colleagues (2008). Although empirical support is still lacking for

 

 

any treatment for adults with anorexia nervosa, CBT-E appears to have the most support and promising future for immediate and long-term recovery (Cooper & Fairburn, 2011; Grave, Calugi, Conti, Doll, & Fairburn, 2013; Fairburn et al., 2013). For patients who are underweight, treatment includes three phases:

1. First step: Help to increase the individual’s readiness and motivation for change. 2. Second step: When the patients are ready, increase caloric intake to regain weight while simultaneously addressing the underlying eating disorder psychopathology, particularly extreme shape and weight concerns. 3. Third step: Focus on relapse prevention by helping patients develop personalized strategies for identifying and immediately correcting any setbacks.