The aim of this report is to show the placement activities and how psychological theory can be applied in a specific occupational environment. During this process I was able to draw on different areas of psychology and demonstrate their relevance to various tasks.  I was able to present my knowledge and understanding in a variety of modes and contexts appropriate to graduate trainnees. I was able to produce a development log reflecting on my work experience, and personal development and achievement during the work placement.

INTRODUCTION

My role in the placement work

This report is a part of the assessment of the Policy and Practice in Health Psychology II module in my MSc Health Psychology program at IST/University of Hertfordshire. As part of the master program, I was required to undertake a 100 hours of supervised work in a health related setting.

This report is my reflection on some of the aspect of work I did during my placement. My placement was done at a Surgical Laparoscopic Clinic in Athens, which specializes in bariatric surgery. My role within the health care setting was divided into three tasks and I was under supervision by a health psychologist. The first task  was to design a psycho-education treatment project as part of Cognitive Behavior Therapy for Binge Eating and Bulimia Nervosa. Every Tuesday and Thursday, I was searching in the literature, to find information in order to support my project. Another task was to observe a session to see the multidisciplinary approach to obesity and eating disorders and bariatric surgery. Furthermore, another task was to observe a pre-arrange cognitive behavioral psychotherapeutic session which I had the opportunity to ask planned questions to answered directly from the patient's point of view. Finally, I participated in a group meetings once a week with my supervisor and two trainnees  for discussing applications of the observation, questions about our projects and barriers in health settings.

Aim of the work placement

The aim of the work placement was to develop trainnee's understanding of the relevance of health psychology to issues of employment and career development. Also as a trainnee, I was able to develop skills in presenting my understanding and knowledge of the psychological material encountered in the curriculum within the context of a working environment.

Section 1

Multidisciplinary approach to obesity and eating disorder and bariatric surgery. Observe the stages of assessment, information giving, pre-surgery support, the dietician and psychologist approach. Treatment planning, a holistic approach.

At this stage of the placement, I had the opportunity to see how a multidisciplinary team works in obesity, eating disorders and bariatric surgery.

Nowadays, obesity is not a problem only for an aesthetic appearance and feel good but for the various health problems that an overweight person develops.  Researches show that an overweight person can develop health problems, such as heart disease, stroke, diabetes, certain types of cancer, sleep apnoea and osteoarthritis. (health problems)As the obesity becomes even a more serious health problem, a scientific medical approach is needed.

If the obese does not see results after a continuous diets or medical drugs, bariatric surgery is a solution for people with BMI above 40. (what is bariatric surgery?) Patients who seek bariatric surgery tupically are required to complete a behavioral examination with a mental health provider to determine their appropriateness for surgery (Devlin,2004). Bariatric surgery candidates should understand how their lives may change after surgery, including nutritional needs and mood (National Institutes of Health, 1991) A multidisciplinary team is also needed because a patient should be selected carefully after evaluation with medical, surgical, psychologist and nutritional expertise. Multidisciplinary team looks for patients which are well informed and motivated and who can discuss weight loss approaches other than surgery and the advantages and disadvantages of each. In addition, the team is able to identify and consider changes in mood and quality of life that may occur with surgery and weight loss. Mental health professionals have been included in the team because studies have shown that this specific population has a high prevalence of psychological or behavior complications. Researches have found that people who have BMI >40kg/m2 is five times more preferable to have experienced an episode of major depression than people with normal weight.  Other studies have shown that 50% of bariatric candidates had experienced a depression. Another responsible factor for the increased rate of depression may be include eating disorders.according to studies, 10% to 25% of bariatric candidates suffer from Binge Eating Disorder (BED) which is characterized by large amount of food in short period (< 2hours). Quality of life seems that affect person's mood and therefore rates of depression. A person who is extremely obese reports greater bodily pain, and impairments in physical functioning, work and social interactions (Fontaine, 1996). Obese people also face discrimination in daily basis things, others often label them as "lazy, ugly and awkward" (Foster,2003).

An evaluation starts with several questions to the bariatric candidate. A set of questions include how well a candidate is informed about the bariatric surgery, the potential risks and benefits and behavioral consequences. Studies have shown that a majority of candidates is well informed about the operation, and a small minority seems that they have general knowledge generally from the media. The multidisciplinary team uses interview to educate such individuals and have a proper discussion with the surgeon or the dietician. The assessment include also questionnaires about reasons for wanting a surgery and if the candidate understand obesity and how affects his life. Weight and dieting history are taking by the dieticien in order to inform about the age of onset of obesity and the history of the condition in parents and other family members. Questions about eating and activity habits are also asked, focusing on the number of meals that an individual eat through the day. It is also include favorite foods and foods typically eaten. Physical activity is briefly assessed in order to find out patients's lifestyle, and according to research, more candidates seem to have low levels of activity and therefore they gain weight more easily. Mental health professionals include psychological assessments to identify psychatric illness and any previous treatment received.

Here is an example of the observation of assessment that I had during my placement: Nutritionist and I met with Mr Kostas who referred for behavioral assessment of his appropriateness for bariatric surgery. Mr Kostas is a 39 years old, male. He is 1,80m with a weight of 110kg and body mass index (BMI) of 34kg/m2. He is single and lives with his parents.

Biological factors

Mr Kostas reported that he was overweight as a child. He had a normal weight from adulthood until 28 years old. After his first episode of depression, he gained weight. The highest weight that he had in his life was 120kg.  Mr Kostas reported that his parents are overweight because of their ages.

Environmental factors

Mr Kostas reported eating two meals and several snacks and sweets each day. He works during the evening and because of that when he returns home eats larger amount of food. Mr Kostas has made one attempt to lose weight in a commercial program. This approach was part successful as the result was 5% weight loss and he has been unable to maintain this loss over long period.

Social / Psychological factors

Mr Kostas has a psychiatric treatment history. He attended psychotherapies for four years by a psychologist and psychiatrist. For the past four years, he has been taking pharmaceutical drugs for dipolic depression.

Section 2

Participate in a pre arrange cognitive-behavioral psychotherapeutic session. Group discussion and analysis of the therapy stages with the patient. Pre planned questions from the trainnees will be answered directly from the patient's point of view. Panic disorder

At this stage, my supervisor arranged a session with a patient who had panic attacks. Me and the other trainnee met the patient in the office of our supervisor. Before that I had prepared questions that I wanted to ask the patient. These questions include: what help the patient to find out that she needs professionaal help, any negative thoughts about visiting the psychologist for the first time, how psychotherapy helped her in order to overcome panic attack, how she feels now after the psychotherapy, how homework assignment helped her. At this time as a health psychology trainne, I realized how psychoeducation helps people with kind of problem. The patient talked to us openly without doubts about her personal problem. We discussed how panic attacks became a barrier for her happiness and calmness, how her family environment and friends faced her problem, and how doctors could not help her to overcome this problem. As her problem started at this age of 25 years old, (now she is 50 years old) tried through different methods to go over of this.

According to DSM-IV, panic attack is "the essential feature of a Panic Attack is a discrete period of intense fear or discomfort in the absence of real danger that is accompanied by at least 4 of 13 somatic or cognitive symptoms" (APA, 2000, p.430).

Section 3

Clinical health psychology project

Design a psycho-education treatment as part of CBT for Eating Disorder and Binge Eating.

Introduction

It is fairly common for all people to overeat or to exhibit different, sometimes excessive, eating patterns from time to time. Eating a lot of food or exhibiting such behaviours occasionally does not mean that one suffers from a disorder. Yet there is a point when one's eating behaviour becomes problematic and some form of eating disorder can be identified and treated.

People who have a binge eating disorder regularly eat an unusual large quantity of food and they feel that their eating is out of control. Moreover, they can eat very fast during their binge eating episodes, eat large quantity of foods even if they are not feel hungry enough, eat because they are depressed or they feel guilty about their eating behavior (NIDDK, 2009).

For the DSM-IV (2002) which has a stricter definition, binge eating disorder refers to a particular form of overeating which can be identified by "eating in a discrete period of time an amount of food that is definitely larger than most people would eat during a similar period of time in similar circumstances", and by "a sense of lack of control over eating during the episode". Binge eating disorder is the most common eating disorder, affecting about 3 percent of adults in the United States, with people between 46 and 55 years being more susceptible (NIDDK, 2009).

Bulimia nervosa is a more serious form of eating disorder that includes the symptoms of binge eating but bulimia is also characterised by the use of compensatory behaviour for the aforementioned overeating. Bulimics are driven by an underlying morbid fear of fat and in order to reduce the effects of their overeating they resort in self-induced vomiting (known as purging), fasting, the use of laxatives, enemas, diuretics or strenuous exercise (Rosenhan, Seligman & Walker, 2001).

The definition of bulimia nervosa provided by the DSM (2002) includes five official criteria: (1) recurrent episodes of binge eating, (2) recurrent inappropriate compensatory behaviour in order to prevent weight gain, (3) the binge eating and inappropriate compensatory behaviours both occur at least twice a week for three months, (4) self-evaluation is unduly influenced by both shape and weight, (5) the disturbance does not occur exclusively during episodes of anorexia nervosa.

Patients suffering from eating disorders have specific personality traits in common, suggesting that these features are vulnerability factors that make some persons more prone to developing such disorders (Engel, Staats-Reiss & Dombeck, 2007). A review of approaches utilised to evaluate models of the relationship between personality and eating disorders has shown that negative emotionality, perfectionism, drive for thinness, poor interoceptive awareness, ineffectiveness, and obsessive-compulsive personality traits are likely predisposing factors. Furthermore, obsessive-compulsive personality disorder (OCPD) and anorexia nervosa share a common familial liability (Lilenfeld et al., 2005). Wonderlich and Mitchell (2005) note that the entire literature addressing the relationship between eating disorders and personality is undeniably influenced by one major factor: the study of the relationship of personality traits and disorders in a period of considerable flux because of methodologic and conceptual problems regarding the nature and measurement of personality. They highlight a relationship between bulimia nervosa and dramatic-erratic personality disorders (impulsivity). In general, bulimia nervosa has been connected to impulsive and narcissistic personality traits.

Treatment

The issue of treatment in eating disorders is tricky, mainly because no biological measure or universally accepted "gold standard" of food intake exists. Simply asking individuals to report how often they binge falls short of what is required.

People with binge eating disorder if they want to  lose weight or they want to reduce the problem, they should ask for a help from health professionals including general practitioners, nutritionists, psychiatrists, and psychologists. Even those that are not overweight they usually are upsetting with their food consumption and their behavior and the treatment can help them (Psychiatric Times, 2007).

There are numerous different ways to treat binge eating disorder. Cognitive-behavioural therapy educate people how to keep journal of what they eat and drink and change their eating habits from unhealthy to healthy ones and also change they way that they react in tough situations.  Researchers are trying to find a treatment that can control binge eating and it will be helpful for overweight people. In addition, a weight loss program that also offers treatment for binge eating it will be the best choice

The main goal of treatment for bulimia is to decrease or stop binge eating and purging behavior. To this end, nutritional treatment, psychosocial intervention with psychotherapy, and medication management strategies are often used. Establishment of a pattern of regular, non-binge meals, progress of attitudes related to the eating disorder, support of healthy but not excessive exercise, and resolution of co-occurring conditions such as mood or anxiety disorders are among the specific aims of these strategies. Individual psychotherapy (especially cognitive-behavioral), that uses a cognitive-behavioral approach, and family or marital therapy have been reported to be effective. Another effective way to treat people who have bulimia, especially those with symptoms of depression or anxiety, psychotropic medication might be helpful if the other methods such as psychosocial treatment and psychotherapy do not work alone.

In addition, these psychotropic medications may prevent relapse. The treatment aim and approach for binge-eating disorder are like to those for bulimia, and studies are estimated at this time the effectiveness and success of various interventions. Other treatment methods include the 'symptom management' approach by Johnson et al. (cited in Lindsay & Powell, 2002). This treatment has various components. One is self-monitoring of food intake, vomiting and preoccupation with food. Initially, this is used as an assessment device, but for most patients it becomes a valued part of their system of control and allows an objective evaluation of intake at times when anxiety prevents proper recall. Some patients have requested diaries to help them get through a difficult time (e.g. Christmass), after the end of formal treatment, and it could well be recommended as a maintenance procedure.

Another component is the modification of food intake. Many patients cannot even remember when they last ate normally and considerable coaching is required. Almost all therapies involved encouraging the patient to relinquish restraint and to return to normal eating. Great stress is placed on continuation of normal eating, even if a binge has occurred. At first it is wise to avoid 'dangerous' foods, but this can be introduced gradually. Some patients have found it very helpful to have copies of diary sheets from normal eater for comparison. Bulimic patients seem surprised to discover that food preoccupation, craving, failures of safety and bingeing are likely to be caused by food deprivation (Lindsay & Powell, 2002).

A third component is exposure to 'forbidden' food. Bulimic patients divide food into two kinds, one is called 'bad', 'forbidden' or 'dangerous', and is consumed only in binge. The other is 'good'. The former is invariably food of a high calorie density while the latter is 'diet food', such as fruit, vegetables, cottage-cheese etc. In response to the sight, thought or taste of dangerous food they become very anxious and conflicted and are at risk of a binge. In order to reduce binge-frequency at first, exposure to binge situations should be limited and the patient helped to recruit support to avoid a binge. Gradually, the feared food can be re-introduced and feared situations re-entered. Exposure seems to be useful and the introduction of 'bad' food eaten first with the therapist and then alone can erode the list of 'bad' foods (Lindsay & Powell, 2002).

Cognitive Behaviour Therapy - Treatment for Binge Eating Disorder and Bulimia Nervosa

It has already refered above that one possible treatment for binge eating is cognitive behavioural therapy (CBT). Briefly, Cognitive behavioural therapy allows patient  to look at the relationship between their thoughts, feelings and actions and in doing so allows them to understand that if they change the way that they think and feel, they will change the way that they act.

CBT can be used in a private therapy session or in a group therapy session independing the problem. Each session lasts 50 minutes and they usually occur once a week. CBT is a short-term treatment, usually lasting  six months  (Waller et al., 2007).

CBT is used to treat the mental and emotional elements of an eating disorder. This type of therapy can change attitudes about eating, food and body image, it can help correct poor eating habits, and prevent relapse. It is considered effective for the treatment of eating disorders. Nonetheless, psychological treatment is required for at least one year if eating disorders can last for a long period, CBT may be more effective in treating bulimia nervosa rather than anorexia nervosa (Waller et al., 2007). People who suffer from eating disorders and especially binge eating or bulimia it is important to understand the relationship between thoughts, emotions and actions. If a patient understood these relationships, he can replace the negative thoughts, which have led him to abnormal eating behavior with positive thoughts and emotions that will lead him in a healthy lifestyle.

In order these relationships build and become clear to the patient, it will tale several weeks of tracking thoughtsand feelings before a person will accept this proof. A therapist often asks from clients to keep a journal and write down their thoughts, feelings, and actions during a week (Waller et al., 2007).

In a randomized controlled study by Fairburn et al. (2009) published in the American Journal of Psychiatry, researchers studied the use of a specific form of CBT designed to treat eating disorders. Cognitive behavioural therapy has proved to be very effective with eating disorders, especially bulimia. It usually follows a specific structure, and a broad outline will be provided below. CBT treatment last for approximately 20 weeks, with ideally one session per week. The treatment is semi-structured, problem-oriented, and it focuses on the patient's present and future rather than his/her past. The first eight sessions comprise the first stage of the treatment. The patient will provide his/her full history and his/her mental state will be examined and assessed by the therapist. Before treatment can actually begin the patient has to be informed about the treatment structure, the treatment content, its likely outcome, and the treatment style and need for commitment on his/her behalf. The therapist and client review together the monitoring sheets that the client completes as a kind of "homework". The therapist will prepare for the patient a daily schedule of what to eat, a motivation planner, use a number of distraction techniques or lists with things that the patient can do to avoid eating. Moreover, the cognitive view of bulimia nervosa is explained, and the patient is educated about weight and eating through the use of examples.

The second stage of cognitive behavioural treatment includes sessions 9 to 16. The therapist and patient work on tackling the issue of the latter's dieting and enhancing his/her problem-solving skills which will assist in the treatment itself. As mentioned above, bulimia is characterised by the patient's concern about his/her weight, a concern that leads to the maladaptive behaviours characteristic of the disorder. During treatment, the therapist addresses the patient's concerns about body shape and weight, as well as other cognitive distortions that the patient may suffer from. The removal of these sources of stress plays a fundamental role in the continuation of treatment.

The third and final stage of therapy includes sessions 17 to 20, although it should be clear by now that these numbers are approximate guidelines and by no means absolute. This stage includes only the last four or so sessions and is more of an epilogue to successful therapy. The patient is encouraged to practice the techniques he/she learned in the first two stages. He/she is also prepared to face possible difficulties in the future such as the prevention of a possible relapse. The patient may use a motivation planner to remind himself/herself of the lessons learned in therapy and read the list everyday. He/she should be ready to respond appropriately to sabotaging thoughts or cognitive errors that he/she may have to face in the future. Finally the patient could use a distraction techniques planner to note down the things he/she can do to avoid eating as learned or suggested in therapy.

According to Wilson (1997), CBT treatment of bulimia and other eating disorders is based on a model that emphasises the critical role of both cognitive and behavioural factors in the maintenance of the disorder. The concept of an idealized body weight and shape seems to play a primary importance. This concept leads women to restrict their food amount in rigid and unrealistic ways, a process that leads them to periodic loss of control over eating (binge eating). Self-induced vomiting and other extreme forms of weight control are attempts to compensate for the effects of binge eating.

Self -induced vomiting helps binge eating because the patient does not afraid that he will gain weight. In turn, self-induced vomiting and binge eating causes distress and low self-esteem and it makes worst the binge eating behavior. Cognitive Behavior model can help this behavior and through therapy, it can change restricting dieting and behavior to more healthy eating patterns. Also Cognitive Behavior model can changes thoughts and behavior which are dysfunctional and lead to self-induced vomiting or binge eating.

CBT for bulimia nervosa has been rigorously evaluated in over 20 controlled trials, and overall three main findings can be identified, showing that CBT appears to be the perfect "tool" for the treatment of the disorder. In short, CBT has greatly beneficial effects on all aspects of the psychopathology of bulimia, the improvement it brings appears to be well-maintained, and it has been found to be equal or superior to all other forms of treatment that have been tested. With CBT, frequencies of binge eating and purging are markedly reduced, dietary restraint is decreased, and the intensity of the concerns about shape and weight are attenuated if not normalized. CBT also has durable effects. Available evidence suggests that therapeutic changes are well-maintained over the six to 12 months following treatment, an impressive outcome for such a brief treatment used on such a chronic disorder. Finally, no other treatment, pharmacological or psychological, equals the efficacy of CBT. Nevertheless, it is also clear that no more than roughly 50% of patients cease binge eating and purging. Of the remainder, some show partial improvement, whereas a small number derive no benefit at all (Wilson, 1997).

Conclusion

Eating disorders are a major health concern in modern societies, both in terms of prevalence as well as in terms of severity. While occasional overeating is a common and relatively harmless behaviour, when it occurs often and uncontrollably it can become problematic and dangerous for the individual. Binge eating disorder and bulimia nervosa are problematic behaviour and health concerns that require treatment. This is where cognitive behavioural therapy plays a very important part. CBT is the ideal form of therapy for eating disorders and bulimia in particular, producing better and longer lasting results than any other kind of treatment.

The application of CBT emphasises the critical role of both cognitive and behavioural factors in the maintenance of the disorder. Treatment addresses more than the obvious behaviours of binge eating and purging. Throughout the therapeutic sessions the patient's distorted modes of thinking and irrational fears are gradually eliminated. A normal eating pattern is established and dysfunctional thoughts and feelings about the personal significance of body weight and shape are altered. Thus, in a relatively small number of sessions which usually take a few months the patient's problematic behaviour is eliminated, along with its deeper underlying causes, and replaced by a more balanced eating behaviour which will be maintained in the future as well.

Section 4

Clinical supervision. Participation in group meetings once a week for discussing applications of the observation, assessment and interview skills, communication skills, therapeutic relationship, barriers in health settings, questions about projects.

References

APA (2000) Diagnostic and Statistical Manual of Mental Disorders IV-TR. (Fourth Edition, Text Revision.) Washington: American Psychiatric Association