EATING DISORDERS 83

recordings are made at key points during the day or week to encompass critical times such as mealtimes or getting on the scales.

Patients sometimes have difficulty in recognising these thought processes. They might report that they were unaware of any thoughts in their minds at all, but only of emotional distress. Alternatively they might be able to report a long stream of distressing thoughts, but find these so familiar that they have difficulty in appreciating their potential significance. In these circumstances, in vivo techniques or techniques using imagination can be employed during treatment sessions to elicit thoughts. Thus the patients may be asked to eat a small amount of fattening food such as chocolate in the presence of the therapist, and to list their thoughts at four stages:

1.before the food is presented;

2.in the presence of food, before eating;

3.during eating;

4.after eating.

Thought listing, in imagination or in vivo, may be used to supplement home-based records as a basis for identifying the presence of dysfunctional thoughts. The skill of making use of this material then lies in selective prompting to enable the patient to make explicit the details and consequences of what might at first appear to be a fleeting or trivial statement.

Carol’s list of thoughts elicited by tasting a small bar of chocolate included statements such as ‘chocolate is unhealthy’; ‘if I have one bit I’ll go on and on eating’. Prompts were used to explore these issues further:

T: What do you mean when you say that chocolate is unhealthy? P: It’s just bad for you.

T: Do you think you can try to explain why that is?

P: It doesn’t have any nutritional value, and it gives you spots. T: What else is it about chocolate which is unhealthy?

P: It makes you fat.

T: Can you tell me how it does that?

P: Everyone knows that chocolate is fattening. It’s got lots of calories in it. T: Can you get fat by eating just that small piece you had just now?

P: Yes—I can feel it just sitting in my stomach. T: And then what will happen?

P: It’ll just stay there and I’ll have a great big stomach and get fat. T: Is that a very frightening idea for you?

P: Yes—I’d hate myself and look ugly.

Thus it is important not to accept merely a conventional, socially acceptable answer elicited by questioning, such as ‘chocolate is fattening’. As a yardstick, prompting and questioning should continue until the point is reached where the therapist can appreciate that the thought would be distressing to the patient personally.

After spending a session on identifying thoughts in this manner, Carol agreed to record them at home whenever a difficult situation related to weight and eating arose. She was also asked to try eating during the week and recording her thoughts. Inspection of these records revealed that she predominantly worried about losing control over her eating by giving in to sweet things, and that any high-calorie foods she ate would go directly to her stomach and thighs.

Dealing with dysfunctional thoughts

The first difficulty in dealing with dysfunctional thoughts arises in deciding which to choose as targets for intervention. This should be agreed together with the patient. It is useful to gather information on dimensions of both intensity and frequency, since these may operate independently. There may be cognitions which do not occur very often, but are highly distressing when they do arise; and others which are extremely frequent, without being perceived as particularly distressing.

Carol was keen to work first on her fears of losing control over her eating, since it was concern over her eating binges which worried her most and motivated her to seek help. Her records showed that she got this thought every time she was offered high-calorie foods, which happened most evenings in the hotel. She felt particularly distressed by this if she was feeling emotionally upset or lonely. With some discussion, the explicit thought was put into words by Carol: ‘Once I start eating something fattening, that’s it. I’ll lose control and go on and on eating and get fat.’

Initially it may be useful to obtain a rating of the patient’s degree of belief in the thought, which can later be compared with her rating after it has been systematically reviewed with her. Such ratings may also be used to monitor fluctuations over time in the degree of belief the thought elicits. Carol believed her statement to be about 85 per cent true at this point in the session.

84 COGNITIVE THERAPY IN CLINICAL PRACTICE

Another step is to explore with the patient the links between the specific cognition and any associated emotions or behavioural patterns.

T: How does it make you feel when you get that thought?

P: I feel anxious; just the sight of food makes me feel nervous sometimes. T: Do you feel any other emotions?

P: I’m not sure really, just nervy I think. T: What about if you taste any of the food?

P: Then I’d feel really guilty, it lasts for ages sometimes.

T: And what about the effects on your behaviour—does that thought affect that in any way? P: I don’t know really.

T: What happens when you do eat? Do you relax and enjoy it?

P: No, I’d just try and eat it as slowly as possible, try and make it last longer than everyone else’s. T: Does it stop you eating at all?

P: Yes, mostly I wouldn’t touch anything I thought was fattening—or else I’d just give in and have a binge.

In attempting to alter a cognition or belief, it is important first of all to understand where it might have come from, and the factors which caused the person to arrive at these conclusions. This may also help to reassure her that she is not being completely irrational in thinking this way. Generally clues may be obtained by enquiry into the past history, to see whether the patient has specific experience which is directly relevant to the conclusions reached.

T: So what is it that made you come to believe that everything you eat will go straight to your stomach and stay there? P: I can just feel that it does—my stomach is so bloated if I eat a proper meal or anything.

T: So one source of evidence is the sensations you get from eating—it makes your stomach feel full. What happens then? P: I make myself sick.

T: What do you think would happen if you didn’t make yourself sick? P: The food would just stay there and make me fat.

There are also likely to be social and cultural factors which have an influence.

T: Was there a time in your past when you thought that you had a big stomach? P: When I was at school—my stomach always used to stick out.

T: And what was your eating like then—did you eat a lot and make yourself sick afterwards? P: I used to eat a lot, but I didn’t make myself sick.

T: And what else makes you worry about your stomach—did people ever comment on it? P: Sometimes they used to call me ‘fattie’ or ‘greedy’ at school.

T: Did that worry you?

P: It didn’t really at the time, but it does more now.

T: What else is it about fat on your stomach that worries you?

P: It’s unhealthy to be fat—you get heart disease and things like that. And nobody wants to go out with you.

The patient may then be encouraged to question whether the conclusions she has reached are entirely valid, and if there are alternative ways of looking at the data or factors which she has not taken into consideration. Emphasis should be placed on helping her to introduce doubts as to the validity of her assertions, rather than providing them for her. Otherwise there is a danger of developing a dialogue where the therapist directly contradicts the patient and undermines her confidence.

T: Do you remember the last time you ate a reasonable amount of food without being sick? P: Yes, it was when I went to visit my mum last week and I couldn’t get away to be sick. T: And what happened that time?

P: I just felt terrible, I couldn’t stand it.

T: Did you carry on feeling just as bad, or did it get a bit better eventually? P: It did get better eventually, but it took ages.

T: What do you think happened to the food in your stomach? P: I don’t know.

T: Is it still there now? P: I suppose not.

T: What usually happens to food after it reaches the stomach? P: It goes right through the system, I suppose.

T:That’s right—it gets digested, doesn’t it. So what would happen if you ate a piece of chocolate now? Would that get digested, or would it stay in your stomach?

EATING DISORDERS 85

P: I’m not sure—I suppose it would get digested.

The main objective of examining alternative explanations is to put across the idea that the thoughts should be seen as beliefs rather than facts. Alternative ways of construing the information should be put forward as potential hypotheses which need to be further investigated, rather than as the correct solution. In order to test out the hypotheses put forward as alternatives to the initial dysfunctional thought, means need to be devised together with the patient. Hypothesis testing might involve direct methods, such as trying out eating a small amount of food in a controlled situation to see whether it leads to bingeing, or asking a sample of people what they typically eat during a day, or finding examples of fat people who are attractive and thin people who are unattractive.

Another useful technique is to ask the patient to take a different perspective, or to imagine how someone else would see the situation from their viewpoint. Choosing a significant person such as a close friend or relative usually allows her to put things into perspective.

T: When people called you fat at school, what did they mean by that? P: They thought I was fat, I suppose.

T: Didn’t you tell me that you’ve never weighed more than eight and a half stone? P: I think that was what I used to be.

T: What would your mother say if you asked her if you used to be fat?

P: She’d say I wasn’t the smallest, but I was about the same size as most of them. I think she’d say I was just average. T: Did anyone else ever get called fat when you were at school?

P: I’m not sure, I can’t remember really.

T: Did you ever call anyone fat, or call them any other names? P: Yes, but that was just teasing.

T: Do you think that people might have been teasing you then, when they called you names?

Inherent in the dysfunctional thought there is usually a feared outcome which seems to threaten intolerable consequences if it should turn out to be true, such as getting fat or losing control in some way. Asking the patient to consider the worst which might possibly happen, and see whether it would really be as bad as they imagined, can provide a method to deal with this.

T: Supposing you did have another binge where you couldn’t stop eating, then what would happen? P: I’d eat and eat and get fatter and fatter.

T: And how bad would that be?

P: It would be just awful, I couldn’t stand it.

T:Just think about it for a moment—supposing you did manage to keep on eating and put on weight—how would it compare to the way you are now?

P: I’d really hate it.

T: Would you feel as tired and ill as you do now?

P: I don’t think I’d feel any worse.

T: Would it be as bad as dying of starvation or coming into hospital?

P: Not really.

T: Would you be able to do your work better than you can now?

P: I suppose I probably could.

T: So how bad would it be compared to the way things are now?

P: It wouldn’t be as bad as this.

T: Do you think there would be anything you could do about it?

P: I suppose I could diet.

T:That’s right—if your weight was very high, you could cut down just a little bit, couldn’t you. Not drastically like you did before, but just enough to get your weight back to normal, and slowly—the same way as we’ve been working to help you put on weight.

Dealing with other areas of concern

The focus of this chapter has been on dealing with concerns relating to eating and weight. Naturally there are other areas of importance to be dealt with, as in the comprehensive treatment of any disorder, but these will not be discussed here, apart from a discussion of the issue of depression. Self-reported depressed mood is extremely common amongst both anorexic and bulimic patients, and may present difficulties during the course of treatment. Whilst the definitive study of antidepressant treatments for eating disorders remains to be conducted, there is no clear evidence that provision of antidepressant medication adds anything to a psychological treatment in most cases (Garfinkel and Garner 1982). If a patient is considered to present a

86 COGNITIVE THERAPY IN CLINICAL PRACTICE

high suicidal risk, hospitalisation should be considered if necessary to keep her safe. If depressed mood does not lift with improvement in the problems associated with eating and body size, it may need to be dealt with separately in the manner described by Beck et al. (1979).

Maintenance and follow-up

Patients should be encouraged to continue to practise the techniques they have learned such as keeping food and thought diaries for as long as they consider these to be useful. They can also be reminded to introduce them again if difficulties recur. After formal treatment sessions have ended, booster sessions may be useful once or twice a year to ensure that progress is maintained.

As in the maintenance of any course of treatment, time should be spent with the patient in considering problems which are likely to arise in the future, and how she will deal with the re-emergence of difficulties which have been dealt with so far. Fairburn’s (1985) programme includes a specific maintenance plan which could usefully be given to the patient at the end of treatment. It should be emphasised that progress and maintenance do not usually follow a smooth course, but tend to take small backward steps now and again which do not imply that any previous improvements have been wasted.

Being a therapist with anorexic and bulimic patients

A number of authors (e.g. Cohler 1977; Selvini-Palazzoli 1978) have highlighted the difficulties from the therapist’s point of view of working with patients with eating disorders. They suggest that this client group is likely to produce particularly strong emotional reactions in the therapist, which may lead to considerable difficulties during the course of treatment.

These emotional reactions may take several forms. A stubborn refusal to eat in the face of life-threatening emaciation may be interpreted by the therapist as a personal insult. It is important in these circumstances to empathise with the degree of terror which the patient may be experiencing at the prospect of change, and her difficulties in accepting help or trusting people. Another difficulty, described by Garner (1985), is a punitive reaction in the therapist. In the light of current cultural ideals, few therapists are likely to be entirely unconcerned about their own body shape and size. Garner (1985) recommends some specific steps which may be taken to deal with these emotional responses towards these patients.

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