Cognitive Behavioural Therapy is based on the study of how individuals process information and how such perceptions form core beliefs that affect an individual's actions.
According to the CBT model of eating disorders, eating disorders represent a combination of cognitive disturbances evident through overvaluing weight, shape, and appearance as well as behavioural disturbances shown through dietary regulation.
According to this model, individuals with eating disorders overvalue weight and shape in an attempt to compensate for feelings of low self-esteem, believing that achieving a certain ideal will enhance their self-worth.
However, individuals with eating disorders hold weight and shape ideals that are either out of reach or only attainable by engaging in turbulent behaviours, which can occur both in the form of extreme dietary restriction and in the form of extreme loss of control or overeating.
In the case of restrictive Anorexia Nervosa, the extreme dietary restriction leads to a state of emaciation, or thinness. In the case of Bulimia Nervosa and Binge Eating Disorder, binge eating bleeds through the attempts at dietary restriction.
Additional dysregulation can occur in the form of compensatory behaviours such as vomiting, laxative and diuretic abuse, all behavioural manifestations of an effort to commit to and achieve unrealistic, self-imposed weight and shape ideals. Additionally, the dysregulation of eating has been understood as an attempt to self-regulate and self-sooth, especially for those individuals who eating disturbance is dominated by binge eating.
The CBT model for eating disorders includes five principles:
1. Self-worth of the individual with an eating disorder is overly determined by body weight, shape and appearance.
One of the diagnostic criteria for Anorexia Nervosa and Bulimia Nervosa is a disturbance in body image. Individuals with eating disorders imbue body weight, shape and appearance with intense meaning and extreme importance and are acutely sensitive to minute changes in weight, shape and appearance. Weight fluctuations that would be imperceptible to others can dominate the experience of an individual with an eating disorder and can have a significant effect on self-worth and mood.
2. Individuals with eating disorders overvalue weight and shape to compensate for feelings of low self-esteem.
The CBT model for eating disorders theorises that low self-esteem is at the core of the overvaluation of weight and shape. For an individual with an eating disorder, the pursuit of thinness is the pursuit of enhanced self-esteem.
While the evidence shows that there is an inverse relationship between self-esteem and the importance of weight and shape (the higher your self-esteem the less weight and shape matter to you), for individuals with eating disorders, the belief that achievement of a physical ideal will enhance self-esteem is held with tenacity. The ironic result is that most individuals with eating disorders are not able to achieve their self-imposed weight and shape ideal, which results in ever-diminishing self-esteem rather that the intended effect of enhanced self-worth.
3. Individuals with eating disorders attempt to self-regulate their emotional world and manage stressful interpersonal situations, at least in part, with food.
The behavioural components of dietary restriction, binge eating and compensatory efforts all play some role in managing emotional states that individuals with eating disorders have difficulty tolerating and managing. Thus, the behavioural components become routing coping strategies – restriction of intake manages anxiety, simplifies decision making, binge eating quells feelings of despair and distracts from feelings of depression, vomiting quiets feelings of self-loathing. But these strategies work only temporarily and at a high cost.
4. Eating disorders are can be caused by multiple factors which can predispose, precipitate and perpetuate an eating disorder.
Eating disorders are not only disorders of weight, shape and eating. Genetic, biological, sociocultural, family and developmental factors can all contribute to an individual’s degree of vulnerability for developing an eating disorder. Some risk factors for eating disorders are common across all disorders, others are specific to one disorder or another.
5. The symptoms of the eating disorder are not simply symbolic representations of underlying problems but are also significant in their own right and require focused attrition.
It may be true that the eating disorder symptoms represent underlying problems at some symbolic level, but they are more than that. They directly affect emotional, behavioural and cognitive processes in such a way that they affect other aspects of psychological and physical health.
The CBT model requires a sound therapeutic relationship between the client and therapist.
The potential of the cognitive behavioural therapy model lies in its ability to engage, challenge and mobilize the client. But its effectiveness depends on the alliance between client and therapist.
According to the CBT model it is especially important for therapists to provide accurate empathy to clients, by seeing situations from the client’s perspective and suspending their own assumptions and judgements.
The goal is to create an honest and trusting client-therapist relationship and this can be achieved when the therapist think strategically and anticipate desired outcomes while challenging any of the client’s faulty reasoning and assumptions, but always at a comfortable pace.
The relationship between the therapist and client is collaborative.
Therapists and clients work together as partners in the CBT model. Each one brings his or her own expertise and neither can do the work alone. Right from the start it is important to communicate to the client that one of the primary goals of therapy is for the client to become his or her own therapist. As treatment progresses, the client assumes increasing responsibility and leadership is determining the focus of the work, both inside and in between sessions.
CBT begins with a focus on the present.
The starting point for CBT is on the current, perpetuating factors of the eating disorder. Addressing the current issues and bringing some resolution of symptoms is the most powerful starting point because it provides brings some immediate relief to the individual and provides tangible effects.
CBT begins with a focus on the eating disorder symptoms.
By the time individuals present for treatment, they have often been living with the eating disorder for an extended time, and the disorder has taken on a life of its own. Cognitive-Behavioural Therapy begins with focused and clear targets for change by focusing on the specific symptoms of the eating disorder on daily functioning. CBT promotes behaviour change by helping individuals modify dysfunctional beliefs and assumptions.
CBT sessions have an explicit structure and duration.
Compared to many other therapeutic approaches, one of the most notable qualities of CBT is the explicit agenda setting and structuring of sessions. Therapy sessions begin with collaborative agenda setting for the sessions by soliciting clients for their input and while considering the therapist’s own recommendations.
Once an explicit agenda for the session is agreed on, the session proceeds with a discussion of identified issues. Time is allocated at the end of the session for a summary of session and a discussion of goals and objectives that can be addressed between sessions. Time limits for treatment sessions aid with the intention of setting goals and evaluating treatment progress explicitly.
Resolution of the eating disorder requires active work outside the therapy session.
Work done outside the therapy sessions is as important as work done in them. It is important to emphasize the importance of work between sessions right from the start. The work between sessions helps to make clear factors that contribute to maintenance of the eating disorder and provides room for experimentation with supportive changes in behaviour. Between-session work can include self-monitoring of eating and engagement in behavioural and cognitive exercises which can help identify problematic patterns.
Psychoeducation is an important component of CBT.
Providing clients with accurate information about important aspects of eating disorder pathology is a core component of CBT. Psychoeducation includes nutritional education, information about the psychological and physiological effects of starvation, the self-perpetuating cycle of binge eating and vomiting, the ineffectiveness of vomiting and laxative abuse to promote weight loss as well as the harmful medical consequences.
Clarifying goals for treatment is crucial and sometimes complicated.
In Cognitive Behavioural Therapy it is extremely important that treatment goals be explicitly stated. Although it might seem obvious that a client’s goal is resolution of the eating disorder, this is often not the case.
Many individuals with Anorexia Nervosa attend sessions only under duress and have a lack of investment in recovery. In cases of Bulimia Nervosa and Binge Eating Disorder, it is not unusual for individuals to be invested in resolution of some but not all the symptoms of the eating disorder.
For example, many individuals with Bulimia Nervosa want to eliminate binge eating and purging; however they do not want to relinquish investment in achieving a certain weight through dieting.
Making apparent the incompatibility of these goals is a core aim of Cognitive Behavioural Therapy. Individuals often have fears and concerns about treatment and recovery that make it difficult for them to fully commit. CBT aims to help individuals articulate such issues so that they can more clearly commit to their goals for treatment and make informed decisions related to recovery.
Issues of motivation will govern the focus and pace of treatment.
A key first step in cognitive behavioural therapy is cultivating and sustaining motivation for change. When clients have difficulty with motivation for treatment it is essential to honestly explore the client’s thinking about the advantages and disadvantages of symptoms. Then based on this shared understanding client and therapist can work to challenge assumptions and promote experimentation, ultimately with the goal of reevaluating fixed cognitive sets and behaviours.
There are certain “non-negotiables” in treatment.
At the start of treatment it is important that the therapist and client establish a contract that specifies the few but critical situations that would alter the therapy focus and process.
This process provides documentation so that each participant clearly understands when treatment will be terminated and what procedures will be followed at that time. These non-negotiable parameters represent an explicit agreement about how to manage imminent danger to self and others.
Across all therapy situations, if a client is perceived to be in
imminent danger of hurting himself/herself or someone else, the normative
agreements concerning focus of treatment and client confidentiality change.
Overall, the goal of Cognitive Behavioural Therapy is to identify problematic perceptions and cognitions an individual may have and to promote healthier, more flexible and adaptive cognitive and behavioural sets.
Thompson, K. J. (2004). Handbook of Eating Disorders and Obesity.
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