Ginny is presenting to Dr. Hamilton with motivation to address her symptoms. Numerous factors—including, but not limited to, anxiety about relinquishing symptoms, shame about one’s behaviors, impaired insight, and comorbid psychiatric conditions—may delay help-seeking in individuals with eating disorders and make the treatment more challenging. As the distress related to the symptoms or consequences of the eating behavior rises, motivation to change may increase. In Ginny’s case, her symptoms are becoming harder for her to tolerate—essentially, the “advantages” of her behaviors (e.g., her perceived control over her weight and body, or any temporary reduction in negative emotional states that she experiences either from the binging or the purging) are beginning to no longer outweigh their disadvantages (e.g., shame, isolation, or negative consequences on her health and functioning), and she is beginning to experience the motivation to change.

Dr. Hamilton will want to capitalize on this motivation, encouraging the part of Ginny that is looking for a way out of her symptoms, while outlining a clear plan of action. A nonjudgmental and knowledgeable stance can be useful when engaging patients with eating disorders, because of the combination of shame about their behaviors and ambivalence about giving up symptoms that is so commonly present. After a full psychiatric history and screening for comorbid conditions, Dr. Hamilton begins by summarizing back to Ginny what she is identifying as negative consequences of her illness, while validating how challenging it must be to seek help and consider change. He then provides psychoeducation about the risks of BN (medical and psychological) and lays out a preliminary plan of treatment. He recommends that she enter an eating disorder day program where she will participate in nutritional counseling, group therapy, and behavioral interventions (e.g., two meals a day at the program with prevention of purging after meals). He acknowledges the anxiety that she describes feeling and suggests a trial of fluoxetine to address anxiety and eating disorder; she begins at 20 mg daily with the plan to increase as indicated.