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Managing Eating Disorders with Cognitive Behavioral Therapy

Like Substance Use Disorders, eating disorders are often a function of deeply ingrained maladaptive core beliefs and assumptions, that not only prescribe the lens through which a client views the world, but also limits his/her reactions to a very distinct pattern of behaviors. These behaviors serve as the primary method through which the client interacts with and attempts to control his/her environment.   In other words, these highly specific assumptions permeate every facet of life and serve to measure success through a very slim range of evaluative factors. These factors are manifested through a dichotomy of judgment – good or bad, black or white, success or failure, skinny or fat. A treatment that attempts to shake the foundation of these core beliefs, expose them as maladaptive and changeable, and then provide the client with the tools needed to effect change, seems the most logical choice.

Cognitive Behavioral Therapy (CBT), a method of psychotherapy developed by Aaron Beck in the 1960s, built upon scientific approaches to reasoning and cognition, Classical and Operant Behavior Theories, and Social Cognitive Theory. In short, CBT posits that maladaptive behaviors can often be traced back to faulty cognitive functioning or “dysfunctional thinking”.

CBT seeks to partner the client and clinician as they embark to re-evaluate and replace these patterns and bring about lasting behavioral change.

Key components of the practice include identifying, evaluating, and modifying automatic thoughts, emotions and behaviors through introduction of new core beliefs, behavioral activation and problem solving skills and training. Of course, facilitative conditions such as authenticity, empathy and respect are also central to this process.

During assessment, past events should be examined in the context of their role in the development of these dysfunctional core beliefs, and attention is given eating behaviors (rituals, rules, frequency of binging/purging/restricting, triggers, etc.). Strengths are highlighted consistently throughout the entire process.

Behaviors serve as the target for change, and reduction of these behaviors as the goal.

Here are some examples of action steps that the client and clinician could take together:

  • Initiate a food journal including his/her thoughts and feelings before, during and after meals.
  • Identify some key reactions in the form of automatic thoughts that function as triggers for bingeing, purging, restricting, etc.
  • Pinpoint environmental influences that contributed to the establishment of these thoughts and assumptions.
  • Attempt to uncover a fundamental core belief through further exploration and questioning about the implications of automatic thoughts and assumptions. Often, in patients with eating disorders, you find that this belief is something like: “I am not good enough” or “I am bad”.

Moving forward, the clinician and client attempt to re-evaluate and modify thoughts, assumptions and behaviors through cognitive restructuring and behavioral experiments. Tools that can be very helpful at this stage are:

  • Self-evaluation pie chart. Client uses a pie chart to denote the importance of certain aspects (family, friends, activities, goals, food, eating disorder) of his/her life. Clients with eating disorders will most likely attribute 75%-95% to their eating disorder. Then, the client draws his/her ideal pie chart, most likely showing a fairly even distribution among all aspects. In addition to identifying some consequences of his/her eating disorder, this chart highlights a “trade-off” implicit in the treatment process. The ideal outcome is that cognitions become malleable, and therefore the client can begin to conceptualize their alternative.
  • Behavioral experiments: For example, clients with eating disorders often engage in several types of “body checking” throughout the day. As one behavioral experiment the client may attempt to go through the week without “pinching” (pinching and folding skin in an attempt to measure “fat”). The goal is to test the belief that engaging in body checking somehow controls perceived inadequacies. This often really resonates with clients and opens them up to suggestions for positive behavior changes.
  • Practicing appropriate identification of feelings. Clinicians will often see that clients mislabel certain emotions as body experiences. For example, all negative emotions blanketed as “feeling fat”. Clients benefit greatly when they begin to identify feelings and label them appropriately.

The ideal outcome is for the client to have learned and practiced identifying negative automatic thoughts, stopping and re-directing the process and engaging in new behaviors as a result. It should be noted that CBT requires active participation of the client; if the client is unwilling to collaborate with the clinician, and has little motivation for treatment, it will most likely not be effective.

Women and men with eating disorders are enslaved by their own core beliefs and assumptions. More importantly, they have little to no awareness of the subjectivity and adaptability of these beliefs and their self-perpetuating behavioral effect. The most potent path toward a client’s empowerment is the realization that they have the ability to change; it is then that a client has the opportunity to take responsibility and begin the creation of their own life.