Reprinted from the "CBT" issue of Visions Journal, 2009, 6 (1), p. 18
Betty had been diagnosed with bulimia nervosa (BN). She was depressed and terrified about gaining weight. One day she didn’t attend her scheduled therapy session.
When I phoned to follow up, Betty explained that she couldn’t come because she knew other people on the bus would be thinking about how “fat” she was.
We took this issue up in our next session, when Betty was able to get a ride in with her mother. Over the course of the session, we discussed body image distortion. This is when a person actually sees and/or feels their body to be larger than it really is. That is, their perception of their size is distorted.
I was able to gently challenge how realistic her thoughts about taking the bus were. At the same time, it was essential for me to accept that her beliefs and concerns are very real for her.
I asked Betty how likely it was that anyone would really notice her in a negative sense. She was able to see just how improbable it was that anyone on the bus would think badly about her or her appearance. Betty was also able to appreciate that people riding a bus were in general more preoccupied with their own thoughts and tasks for the day than concerned about her appearance.
While this may sound like a common sense approach to take in this situation, it’s an example of cognitive-behavioural therapy, or CBT. The “cognitive” refers to thoughts. The “behavioural” refers to the person actually doing real-world things that demonstrate that their thoughts are unhealthy and, ultimately, don’t reflect reality.
The CBT model
The CBT view is that people’s emotional states are a result of how they think about or interpret different situations and not necessarily an inevitable result of the particular situation.
Let’s look at the example of Betty getting on a bus. Due to her marked preoccupation with her weight and shape, it’s not unusual that she’d assume others would be similarly preoccupied with her weight. She might get on the bus and notice another passenger looking at her. Her initial tendency might be to conclude: “That person agrees that I’m fat and shouldn’t be out in public.” This thought would reinforce her belief that she’s “fat” and needs to lose weight, and would lead her to feel very badly about herself.
However, in the same situation, a person could alternatively conclude that the passenger looking at them is admiring their clothing or appearance. If Betty thought this way, she wouldn’t feel badly at all.
So we have two identical situations that resulted in each person feeling very differently later on. Each of these people has attempted to understand, explain and interpret why the person on the bus was looking at them. But they each thought very differently about the situation.
These types of thoughts are called “automatic thoughts.” They are automatic because they happen very quickly. Sometimes they are helpful and allow us to evaluate a situation quickly, but other times they’re very negative and unrealistic.
If the thoughts tend to be very self-critical, it’s not hard to understand how someone could feel depressed as a result of the thoughts. If the thoughts tend to be threatening and involve the future, we can understand how someone might feel very anxious. With an eating disorder, the thoughts often similarly involve depression and anxiety, but include thoughts related to the person’s feelings about their shape and weight.
What is the evidence for CBT in the treatment of eating disorders?
CBT has been researched more than any other psychotherapy in the treatment of eating disorders. This is particularly true in the treatment of bulimia nervosa (BN).1
As a result, we can say with certainty that CBT is the treatment of choice for adults with BN.2 CBT’s efficacy in the treatment of people with anorexia nervosa is less clear. It’s also unclear whether CBT has the same success with youth suffering from BN, since there’s a lack of research and scientific data in this area. In my experience, however, there’s little reason to doubt that CBT is equally effective if modified to fit this younger age group.
At the same time, it’s important to remember that CBT is not a cure-all for every patient with BN, and further research to increase its effectiveness as a treatment is needed.
Traditional CBT for bulimia in practise
Traditional CBT has long been applied to bulimia nervosa and is often referred to as CBT-BN. The initial goals are to interrupt the symptoms, such as bingeing and purging.3 Later, the main task is to help the patient question and challenge the thoughts and beliefs that maintain the eating disorder.
There are usually a limited number of CBT sessions (19 over 18 weeks),3 and homework is typically assigned at the end of each session. The homework is usually a combination of self-monitoring and behavioural “experiments” to be carried out between therapy sessions.
Self-monitoring is where the patient is asked to keep a log or journal of situations, thoughts and resulting feelings. With Betty, I designed a form she could use to record her negative thoughts and feelings, how these related to particular situations and whether she restricted, binged and/or purged as a result.
This journalling is intended to increase awareness that eating-disordered behaviours take place in a context of thinking and feeling. The patient becomes much more aware of their thinking, which helps to take the eating-disordered behaviours off “automatic pilot.”
Self-monitoring must be introduced gradually. Just learning to distinguish between a “thought” and a “feeling” can be very difficult. For some people with eating disorders, learning to tell the difference between certain feelings—distinguishing between hurt and anger, for instance—is an important and crucial step. One may need to begin by learning names for various feeling states. The person can then develop, as would an artist, a more varied palette for expressing and describing their feelings. Disappointment, frustration, boredom, loneliness and more may be identified.
Another goal is to help patients learn to classify their cognitive distortions into different categories. These categories include “all-or-nothing” thinking, “mind reading,” “emotional reasoning,” “personalization,” and so on.** An example of all-or-nothing thinking (also known as “black and white” thinking) is the patient seeing him or herself as only very thin or fat—there are no in-betweens. Being able to classify thought distortions helps patients appreciate that their thoughts are unrealistic.
It’s very helpful for a patient to learn strategies for challenging automatic negative thoughts. For example, we help the patient ask, “What is the evidence?” for negative thoughts related to body image distortion. This can empower the patient to work at diminishing the power these thoughts have.
These thoughts don’t simply disappear upon first challenge; they must be challenged repeatedly. Patients also begin to become aware of recurring themes related to their thoughts. Feeling they don’t deserve to receive help is an example of such a theme.4
On a level deeper than automatic thoughts lie schemas, which are more enduring beliefs. These help determine the person’s experience of being-in-the-world. An example would be the belief that, “No one would like me if they really got to know me.”5 And again, the patient can question what evidence there is for their beliefs.
The best way to disprove the apparent truth of negative thoughts and beliefs is through real-world experiments. The patient is asked to collect “data” both in support of and against the belief. For example, Betty will be encouraged to take graduated risks with normalizing her eating behaviour, to test out the eating-disordered thought that she will gain weight in an out-of-control fashion.
Sometimes I use a “courtroom and lawyer” analogy. Negative automatic thoughts tend to have a persecutory quality. I make it clear that the eating disorder is like a prosecutor in court. Patients are aware that cases are thrown out of court when the apparent “evidence” the prosecutor brings forward is seen as insubstantial. CBT helps patients learn to question the “evidence” that the eating disorder brings forward.
Over time, Betty will learn to challenge her eating-disordered thoughts and beliefs on her own. And she’ll be able to take increasing charge of her mood. This will help to restore a sense of control, a sense of choice and her self-esteem.
CBT-E and other CBT offshoots show promise
Enhanced CBT, or CBT-E, is a relatively new form of this therapy. A five-year study suggests that CBT-E is “more potent” than CBT-BN.6 In CBT-E, the traditional CBT model of bulimia nervosa treatment has been broadened to treat all the eating disorders. It has added modules that target perfectionism, self-esteem issues and relationship challenges. There is also a version for patients less than 18 years of age.
There’s further good news. There are many other offshoots of classic CBT that show promise in helping patients with eating disorders. These include dialectical behaviour therapy,7 acceptance and commitment therapy8 and those approaches derived from the emerging literature on mindfulness.8-9
About the author
Ron is a psychologist with the Provincial Specialized Eating Disorders Program for Children and Adolescents at BC Children’s Hospital. He has worked in the field of eating disorders for over 25 years.
Ron thanks his colleague Dr. Karina O’Brien for her helpful comments on an earlier draft of this article.
Marrone, S., Mitchell, J.E., Crosby, R. et al. (2009). Predictors of response to cognitive-behavioral treatment for bulimia nervosa delivered via telemedicine versus face-to-face. International Journal of Eating Disorders, 42(3), 222-227.
Mitchell, J.E., Agras, S. & Wonderlich, S. (2007). Treatment of bulimia nervosa: Where are we and where are we going? International Journal of Eating Disorders, 40(2), 95-101.
Fairburn, C.G. (1984). Cognitive-behavioral treatment for bulimia. In D.M. Garner & P.E. Garfinkel (Eds.), Handbook of psychotherapy for anorexia nervosa and bulimia. New York: Guilford Press.
Manley, R.S. & Leichner, P. (2003). Anguish and despair in adolescents with eating disorders. Crisis, 24(1), 32-36.
Root, M.P.P., Fallon, P. & Friedrich, W.N. (1986). Bulimia: A systems approach to treatment. New York: W.W. Norton & Company.
Fairburn, C.G. (2008). Cognitive behavior therapy and eating disorders. New York: Guilford Press.
Safer, D., Telch, C. & Chen, E. (2009). Dialectical behavior therapy for binge eating and bulimia. New York: Guilford Press.
Hayes, S.C., Follette, V.M. & Linehan, M.M. (Eds.) (2004). Mindfulness and acceptance: Expanding the cognitive-behavioral tradition. New York: Guilford Press.
Kristeller, J.L. & Hallett, C.B. (1999). An exploratory study of a meditation-based intervention for binge eating disorder. Journal of Health Psychology. 4(3), 357-363.