Cambridge University Press
978-0-521-67248-1 - Cognitive Behavioral Therapy for Eating Disorders - by Glenn Waller
Front Matter

Cognitive Behavioral Therapy for Eating Disorders

A Comprehensive Treatment Guide

This book describes the application of cognitive behavioral principles to patients with a wide range of eating disorders: it covers those with straightforward problems and those with more complex conditions or comorbid states. The book takes a highly pragmatic view. It is based on evidence published, but stresses the importance of individualized, principle-based clinical work. It describes the techniques within the widest clinical context, for use across the age range and from referral to discharge. Throughout the text, the links between theory and practice are highlighted in order to stress the importance of the flexible application of skills to each new situation. Case studies and sample dialogues are employed to demonstrate the principles in action and the book concludes with a set of useful handouts for patients and other tools. This book will be essential reading for all those working with eating-disordered patients including psychologists, psychiatrists, nurses, occupational therapists, counsellors and dietitians.

Glenn Waller is Consultant Clinical Psychologist with the Vincent Square Eating Disorders Service, Central and North West London Mental Health NHS Trust and is Visiting Professor of Psychology at the Institute of Psychiatry, King's College London.

Helen Cordery is a Registered Dietitian with the St. George s Eating Disorders Service, and Kingston Hospital NHS Trust.

Emma Corstorphine is a Principal Clinical Psychologist with the St. George's Eating Disorders Service, South West London & St George's Mental Health NHS Trust and Visiting Research Fellow at the Institute of Psychiatry, King's College London.

Hendrik Hinrichsen is a Principal Clinical Psychologist with the St. George's Eating Disorders Service, South West London & St George's Mental Health NHS Trust and Visiting Research Fellow at the Institute of Psychiatry, King's College London.

Rachel Lawson is a Senior Clinical Psychologist, South Island Eating Disorders Service, Canterbury District Health Board, and Visiting Research Fellow at the Institute of Psychiatry, King's College London.

Victoria Mountford is a Chartered Clinical Psychologist with the St. George's Eating Disorders Service, South West London & St George's Mental Health NHS Trust and Visiting Research Fellow at the Institute of Psychiatry, King's College London.

Katie Russell is a Chartered Clinical Psychologist with the St. George's Eating Disorders Service, South West London & St George's Mental Health NHS Trust.

Cognitive Behavioral Therapy for Eating Disorders

A Comprehensive Treatment Guide

Glenn Waller

Helen Cordery

Emma Corstorphine

Hendrik Hinrichsen

Rachel Lawson

Victoria Mountford

Katie Russell

CAMBRIDGE UNIVERSITY PRESS
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Cambridge University Press
The Edinburgh Building, Cambridge CB2 8RU, UK

Published in the United States of America by Cambridge University Press, New York

www.cambridge.org
Information on this title: www.cambridge.org/9780521672481

This publication is in copyright. Subject to statutory exception and to the provisions of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press.

First published 2007

Printed in the United Kingdom at the University Press, Cambridge

A catalog record for this publication is available from the British Library

Library of Congress Cataloging in Publication data

Cognitive behavioural therapy for the eating disorders: a comprehensive treatment guide / Glenn Waller . . .
[et al.].
p. ; cm.
Includes bibliographical references.
ISBN-13: 978-0-521-67248-1 (pbk.)
ISBN-10: 0-521-67248-1 (pbk.)
1. Eating disorders--Treatment. 2. Cognitive therapy. 3. Behavior therapy. I. Waller, Glenn.
[DNLM: 1. Eating Disorders--therapy. 2. Cognitive Therapy. WM 175 C676 2007]
RC552.E18C6464 2007
616.85′2606--dc22
2006102403

ISBN-13 978-0-521-67248-1 paperback
ISBN-10 0-521-67248-1 paperback

Cambridge University Press has no responsibility for the persistence or accuracy of URLs for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate.

Every effort has been made in preparing this publication to provide accurate and up-to-date information which is in accord with accepted standards and practice at the time of publication. Although case histories are drawn from actual cases, every effort has been made to disguise the identities of the individuals involved. Nevertheless, the authors, editors and publishers can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. The authors, editors and publishers therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this publication. Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use.

To our families.

Acknowledgments

We would like to thank a range of people and organizations for their inspiration and support in writing this book. They include:

our colleagues on our multidisciplinary teams (particularly Joan Brunton, for her advice on medical risk matters);

our employers (South West London and St. George's Mental Health NHS Trust; Kingston Hospital NHS Trust; Central and North West London Mental Health NHS Trust);

the trainees, students and assistants who we have worked with;

the clinicians and researchers who have inspired us; and

the patients who have provided both challenges to our preconceptions and support for our work.

	Preface	page xxiii

Section I	Introduction

1	The philosophical and theoretical stance behind CBT	3
	1.1 The importance of evidence	3
	1.2 Dealing with the whole person in treatment	4
	1.3 Clinician stance: the curious clinician	4
	1.3.1 Collaborative working relationships	5
	1.4 The transdiagnostic approach	6
	1.4.1 Using the transdiagnostic model in practice	7
	1.5 Themes in the process of treatment	7
	1.5.1 Short-term discomfort in order to achieve long-term gain	8
	1.5.2 The patient becoming his or her own therapist	9
	1.5.3 Continuum thinking	10
	1.5.4 Goal-setting	10
	1.6 The value of case formulation	11
	1.7 The importance of behavioral experiments	11

2	Broad stages in CBT and format of delivery	13
	2.1 Broad stages in CBT for the eating disorders	13
	2.2 Duration of treatment and when to expect change	14
	2.3 Format of treatment	15

3	What the clinician needs to establish before starting	16
	3.1 Medical safety	16
	3.2 Risk assessment in eating disorders	17
	3.3 Who is at medical risk?	17
	3.4 Assessing acute risk at the beginning of treatment	18
	3.4.1 Recent weight changes	19
	3.4.2 Non invasive tests for muscle strength: the sit up, squat, stand (SUSS) test	20
	3.5 Care planning in response to the baseline physical tests	21
	3.6 Assessing chronic risk	21
	3.7 Monitoring risk during treatment	22
	3.7.1 When to stop CBT because medical risk is the priority	22
	3.8 The value of a multidisciplinary working environment	23
	3.9 Preparing the physical environment	25
	3.10 Trouble-shooting: realistic expectations of CBT	25
	Summary	27

Section II	Core clinical skills for use in CBT with the eating disorders

4	Assessment	31
	4.1 Areas covered in interview	31
	4.1.1 Demographic information	32
	4.1.2 Eating behaviors	32
	4.1.3 Measuring the patient's height and weight	33
	4.1.4 Psychosexual functioning and history	34
	4.1.5 Central cognitive elements	34
	4.1.5.1 Body concept/dissatisfaction	34
	4.1.5.2 Body percept	35
	4.1.5.3 Fear of fatness and weight gain	35
	4.1.6 Eating disorder diagnosis	36
	4.1.7 General health	37
	4.1.8 Comorbid behaviors and psychological disturbances	37
	4.1.9 Risk assessment	38
	4.1.10 Treatment history	38
	4.1.11 Family structure	38
	4.1.12 Life history	38
	4.1.13 Client's motivation and goals for treatment	39
	4.1.14 Treatment preferences	39
	4.1.15 Additional assessment of cognitions, emotions and behaviors	39
	4.2 Trouble-shooting in the assessment phase	39
	4.2.1 Extended assessment	40
	4.2.2 Therapy-interfering behaviors	40
	4.2.3 Address the patient's refusal to be weighed	40

5	Preparing the patient for treatment	42

6	Motivation	44
	6.1 Context for motivation: understanding the patient and building a relationship	44
	6.1.1 Understanding the patient's position	44
	6.1.2 The clinician's position	45
	6.1.3 Clinician and patient investment	46
	6.1.4 Stages of change	47
	6.1.4.1 Precontemplation (“not ready”)	47
	6.1.4.2 Contemplation (“thinking about it”)	48
	6.1.4.3 Preparation (“getting ready for change”)	48
	6.1.4.4 Action (“ready, set, go”)	48
	6.1.4.5 Maintenance (“hanging in there”)	48
	6.1.5 Willingness and resources: two components of change	49
	6.2 Assessing motivation for change	50
	6.2.1 Questionnaire and interview measures	50
	6.2.2 Pros and cons lists	50
	6.2.3 The “miracle question”	51
	6.2.4 Motivation as a moving target	55
	6.3 Tools and techniques to enhance motivation	55
	6.3.1 Friend or foe letters	56
	6.3.2 Life plans	57
	6.3.3 Writing to oneself in the future	58
	6.3.4 Pros and cons of change	59
	6.3.5 Problems and goals	60
	6.3.6 Developing and using a summary flashcard	61
	6.4 Trouble-shooting: common problems in motivational analysis and enhancement	61
	6.4.1 Addressing fluctuations in motivation	61
	6.4.2 Pros and cons of the change process	62
	6.4.3 Letting go of the eating disorder	64
	6.4.4 When the patient is not ready to change	66

7	A guide to important dietary and nutritional issues	68
	7.1 What food is used for in the eating disorders	68
	7.2 A beginner's guide to nutrition: what clinicians and patients need to know	69
	7.3 What should a basic meal plan look like?	71
	7.3.1 Meals	76
	7.3.2 Snacks	76
	7.3.3 Calcium-rich foods	77
	7.3.4 Fruit and vegetables	78
	7.3.5 Traditional desserts/fun foods	79
	7.3.6 Fluid requirements	79
	7.4 Food planning versus counting calories	81
	7.5 Helping patients to improve diet: getting started	82
	7.5.1 Planning changes in diet	83
	7.5.1.1 Timing of eating	84
	7.5.1.2 Content	84
	7.6 Working with patients who are underweight or overweight	85
	7.6.1 Managing weight gain in underweight patients	85
	7.6.1.1 How much extra does the patient need to eat to gain weight?	85
	7.6.1.2 Changes in metabolic rate/energy needs during weight gain	86
	7.6.1.3 How to practically manage weight gain in low-weight patients	87
	7.6.2 Patients who are overweight or obese	87
	7.6.3 Vegetarianism and veganism	88
	7.6.4 Vitamin and mineral supplements	90
	7.6.5 Activity	91
	7.6.5.1 Healthy activity levels	91
	7.6.5.2 Compulsive versus excessive activity	91
	7.6.6 Alcohol	92
	7.6.6.1 Advising patients on appropriate alcohol consumption	92
	7.6.7 Patients needing individual dietetic input	93
	7.7 Psychoeducation topics in dietetic work	94
	7.8 Summary	95

8	Case formulation	96
	8.1 What is a case formulation?	96
	8.1.1 Why do we need individualized formulation in CBT?	97
	8.2 Constructing a formulation: general points	97
	8.2.1 How to get started: some basic principles	97
	8.2.2 Which cognitive-behavioral models can guide your formulation?	98
	8.2.3 Formulating transdiagnostically	98
	8.3 Understanding and formulating bulimic cases	99
	8.3.1 A dysfunctional system for evaluating self-worth	99
	8.3.2 Extreme dietary rules and rule violations	99
	8.3.3 Longer-term consequences: dieting versus bingeing and purging	100
	8.3.4 Emotion-driven eating behaviors	100
	8.3.5 How to do it: essential steps in constructing a case formulation	101
	8.3.5.1 Focus on the patient’s eating problems	101
	8.3.5.2 Uncover the patient’s dietary rules	101
	8.3.5.3 Introduce the idea of emotion-driven bingeing	102
	8.3.5.4 Identify overevaluation of eating, shape and weight	102
	8.3.5.5 Obtain feedback and use the formulation to guide treatment	102
	8.3.5.6 Formulation example: the dialogue with a patient with a bulimic presentation	102
	8.4 Understanding and formulating restriction-based cases	106
	8.4.1 Starting the formulation with restrictive cases	107
	8.4.2 Formulation example: the dialogue with a patient with anorexia nervosa	107
	8.4.2.1 Dialogue	107
	8.4.2.2 Drawing Karen’s draft formulation	110
	8.5 The more complex the patient, the more important the formulation	110
	8.6 Checking whether your formulation is accurate	110
	8.6.1 Parsimony	111
	8.6.2 Behavioral experiments are the next step	112
	8.7 How to get good at formulating	112

9	Therapy interfering behaviors	114
	9.1 Naming the reasons for therapeutic disruption: therapy interfering behaviors	115
	9.1.1 A framework for understanding treatment: the river analogy	116
	9.2 Responding to therapy interfering behaviors	116
	9.2.1 Using short-term contracts	117
	9.2.2 The five-minute session	117
	9.3 Particular patient groups	119

10	Homework	120
	10.1 Explaining homework	120
	10.1.1 Audiotaping of sessions for review as part of homework	121
	10.2 General guidelines for agreeing homework assignments	122
	10.2.1 Explain the rationale for the homework to the patient	122
	10.2.2 Ask the patient to explain the rationale for the homework to you	122
	10.2.3 Specify exactly what the patient should do and how they should do it	123
	10.2.4 Practice the homework assignment with the patient in the session	123
	10.2.5 Ask the patient about any concerns regarding carrying out the homework assignment	123
	10.2.6 Summarize the homework	123
	10.3 Dealing with homework non-compliance	124

11	Surviving as an effective clinician	126
	11.1 The physical aspects of an eating disorder	126
	11.1.1 Physical risks in the eating disorders	126
	11.1.2 The act of weighing in the therapeutic relationship	127
	11.1.3 Weight as a communication	127
	11.1.4 Dealing with food-related issues without panic	128
	11.2 The nature of the disorder	128
	11.2.1 The egosyntonic nature of symptoms	129
	11.2.2 Chronicity	129
	11.2.3 The “special” patient	130
	11.2.4 “Manipulation”	130
	11.3 Personal characteristics of patients and clinicians	130
	11.3.1 What brings us to this work?	131
	11.3.2 Issues with body image	131
	11.3.3 Power differentials	131
	11.3.4 How the patient relates to the clinician	132
	11.4 How to survive as an effective clinician	132
	11.4.1 A collaborative stance	132
	11.4.2 Supervision	133
	11.4.3 Team working	133
	11.4.4 Balanced working	134
	11.4.5 Taking care of ourselves when personal matters may impact on us	134
	11.4.6 Making mistakes or letting the patient down unexpectedly	134
	11.5 Summary	135

12	Setting and maintaining an agenda	136
	12.1 General agenda of all CBT sessions	136
	12.1.1 Monitoring mood and eating	136
	12.1.2 “Standing” agenda items	136
	12.2 How to set the agenda	137
	12.3 Some practical points about agenda setting	137
	12.3.1 Do it collaboratively	137
	12.3.2 Keep an eye on time	137
	12.3.3 Maintain appropriate flexibility	138
	12.3.4 Solving problems that arise when working within the agenda	138
	12.3.4.1 Problem 1: the first problem discussed takes up too much time	138
	12.3.4.2 Problem 2: the patient has set the agenda but is unwilling to stick to it	138

13	Psychoeducation	140
	13.1 When to use psychoeducation	142
	13.2 How to use psychoeducation effectively	142
	13.3 Using the internet as a psychoeducation resource	143
	13.4 Key psychoeducation topics	143
	13.4.1 The psychological effects of starvation	143
	13.4.2 The use of the “energy graph” to help the patient to understand their energy requirements	145
	13.4.2.1 Step 1: preparing the patient for the use of the energy graph	146
	13.4.2.2 Step 2: completing the energy graph with the patient on the whiteboard	146
	13.4.2.3 Step 3: making links between the patient's eating pattern and their levels of energy throughout the day	148
	13.4.2.4 Step 4: discussing with the patient how they can start to normalize their energy supply	148
	13.5 Some myths about eating that can be addressed through psychoeducation	150
	13.5.1 Myth 1: My bingeing is uncontrollable and happens at random	150
	13.5.2 Myth 2: I can learn to control my eating through restriction	151
	13.5.3 Myth 3: vomiting after bingeing is an effective strategy to prevent weight gain	151
	13.5.4 Myth 4: taking laxatives is an effective strategy to prevent weight gain	152
	13.5.5 Myth 5: using vomiting and taking laxatives is not really dangerous to one's health	152
	13.5.6 Myth 6: eating food before going to bed results in significant weight gain, because the body is not “burning off” the food while you sleep	152
	13.5.7 Myth 7: fat/carbohydrates make people fat and therefore need to be avoided	152
	13.6 Summary	153

14	Diaries	154
	14.1 Rationale for use of diaries	154
	14.2 What does a diary look like?	155
	14.3 How to address difficulties in completing diaries	157
	14.4 Reviewing the diary with the patient	158
	14.5 Advanced diary monitoring	159
	14.6 When to stop using food diaries	160
	14.7 The limitations of food diaries	160
	14.8 Summary	161

15	The role of weighing in CBT	162
	15.1 Constructing a weight graph	163
	15.2 The weighing procedure: case example	165
	15.3 What can the patient learn from the weekly weighing?	167
	15.4 Introducing the idea that the patient's weight might be genetically determined	170
	15.5 Challenging the patient's belief that their weight will increase uncontrollably	171
	15.6 The role of weighing in the future	172
	Summary	174

Section III	Core CBT skills as relevant to the eating disorders

16	Socratic questioning	177
	16.1 How to engage in the process of Socratic questioning	177

17	Downward arrowing	179
	17.1 How to do it	180
	17.2 Case example: Sarah	180
	17.3 Trouble-shooting	182

18	Cognitive restructuring	183

19	Continuum thinking	184
	19.1 Addressing negative automatic thoughts and core beliefs: working with single dimensions	184
	19.2 Addressing conditional beliefs: working with two dimensions	185

20	Positive data logs	187
	20.1 Case example	187
	20.2 Trouble-shooting	188

21	Behavioral experiments	190
	21.1 How to design effective behavioral experiments	191
	21.1.1 Hypothesis-testing experiments	191
	21.1.2 Discovery experiments	192
	21.2 Observational experiments	192
	21.3 Surveys	193
	Summary	194

Section IV	Addressing eating, shape and weight concerns in the eating disorders

22	Overevaluation of eating, weight and shape	197
	22.1 Cognitive and behavioral manifestations of the overevaluation of eating, shape and weight	198
	22.2 Case formulation using overvalued beliefs	199
	22.3 Alerting the patient to the importance of overevaluation: the self-evaluation pie chart	202
	22.4 Cognitive and behavioral treatment strategies for modifying overevaluation of eating, weight and shape	205
	22.4.1 Cognitive restructuring	206
	22.4.1.1 Evaluating evidence for and against the belief	206
	22.4.1.2 The use of continuum thinking in modifying overvalued beliefs	208
	22.4.1.3 Surveys	211
	22.4.2 Behavioral experiments	213
	22.4.2.1 Behavioral experiments to address beliefs about uncontrollable weight gain	214
	22.4.2.2 Behavioral experiments to address beliefs about acceptability to others	220
	22.4.3 Using the “anorexic gremlin” to assist in implementing CBT techniques	221
	22.5 Summary	223

23	Body image	224
	23.1 What is body image?	225
	23.2 The aim of treatment: acceptance rather than satisfaction	226
	23.3 Background to treatment of body image	227
	23.3.1 Developing a formulation to understand body image	227
	23.3.1.1 Using imagery to explore the meaning and emotional valence of body image	228
	23.3.1.2 Uncovering beliefs associated with body image	228
	23.4 Psychoeducation regarding body image	229
	23.4.1 Understanding the functions of the body	229
	23.4.2 The role of physiology	230
	23.4.2.1 Set point model	230
	23.4.2.2 The need for body fat tissue for healthy biological functioning	230
	23.4.3 The role of societal attitudes towards beauty	231
	23.5 Treatment of body image	231
	23.5.1 Cognitive restructuring	232
	23.5.1.1 Using a pros and cons matrix	232
	23.5.1.2 Monitoring body awareness and judgements	232
	23.5.1.3 Mislabeling emotions	233
	23.5.2 Behavioral experiments	233
	23.5.2.1 Body avoidance and checking	233
	23.5.2.2 Body comparison	234
	23.5.3 Exposure-based methods	235
	23.5.3.1 Body image exposure	235
	23.5.4 Imagery and body image	236
	23.5.4.1 Using imagery to challenge the anorexic voice	236
	23.5.4.2 Imagery work when beliefs about body image relate to early negative experiences	237
	23.6 Summary	238
	Summary	239

Section V	When the standard approach to CBT is not enough

24	Comorbidity with Axis I pathology	245
	24.1 General principles	245
	24.2 Depression and low self-esteem	246
	24.2.1 Assessment	246
	24.2.2 Formulation	246
	24.2.3 Treatment	247
	24.2.3.1 Cognitive restructuring	248
	24.2.3.2 Behavioral activation and experiments	249
	24.3 Obsessive-compulsive disorder	249
	24.3.1 Assessment	250
	24.3.2 Formulation	250
	24.3.3 Treatment	250
	24.3.3.1 Cognitive restructuring	251
	24.3.3.2 Behavioral experiments	253
	24.4 Social anxiety and social phobia	253
	24.4.1 Assessment	254
	24.4.2 Formulation	254
	24.4.3 Treatment	256
	24.5 Posttraumatic stress disorder	258
	24.5.1 Assessment	258
	24.5.2 Formulation	258
	24.5.3 Treatment	259
	24.6 Impulsive behaviors and multiimpulsivity	262
	24.6.1 Assessment	263
	24.6.2 Formulation	264
	24.6.3 Treatment	264

25	Comorbidity with Axis II pathology	266
	25.1 Working with emotional regulation: dialectical behavior therapy methods	267
	25.2 Working with beliefs about emotions: cognitive- emotional-behavioral therapy for the eating disorders	269
	25.2.1 Origins of affect regulation problems	270
	25.2.2 An introduction to CEBT-ED	270
	25.2.3 Formulation for CEBT-ED	271
	25.2.4 Intervention	271
	25.3 Working with core beliefs: schema-focused CBT for the eating disorders	273
	25.3.1 Preparing the patient for SFCBT	273
	25.3.2 Assessment	274
	25.3.3 SFCBT formulation	274
	25.3.3.1 General principles	275
	25.3.3.2 Individual case formulation	277
	25.3.4 Intervention	278
	25.3.4.1 Historical review	279
	25.3.4.2 Diaries and dysfunctional thought records	280
	25.3.4.3 Therapy records	280
	25.3.4.4 Flashcards	280
	25.3.4.5 Positive data logs	281
	25.3.4.6 Schema dialogue	282
	25.3.4.7 Using others as a reference point	283
	25.3.4.8 Imagery rescripting	283
	25.3.5 Working on residual eating issues and other behaviors	283
	25.3.6 Relapse prevention	283
	Summary	285

Section VI	CBT for children and adolescents with eating disorders and their families

26	CBT for children and adolescents with eating disorders and their families	289
	26.1 Diagnostic categories	290
	26.2 Considerations when working with this age group	291
	26.2.1 General considerations	291
	26.2.1.1 Intellectual and emotional capacities	291
	26.2.1.2 Identity formation	291
	26.2.1.3 Working with families	292
	26.2.1.4 Education	293
	26.2.1.5 Friendships and peers	293
	26.2.2 Specific considerations when working with young people with eating disorders	294
	26.2.2.1 Physical issues	294
	26.2.2.2 Clinician stance	295
	26.2.2.3 Motivation: the young person and their family	295
	26.2.2.4 Tips for aiding engagement	296
	26.2.2.5 Confidentiality	298
	26.2.2.6 Comorbidity	299
	26.2.2.7 The importance of working within a multidisciplinary team	299
	26.3 Assessment	300
	26.3.1 The purpose of assessment	301
	26.3.2 What information do you want?	302
	26.3.3 Tips to aid in getting the information required	302
	26.4 Motivation	303
	26.4.1 Motivational techniques	304
	26.5 Case formulation	306
	26.6 Interventions	309
	26.6.1 Motivational enhancement	310
	26.6.2 Cognitive-behavioral change	310
	26.6.2.1 General considerations	311
	26.6.2.2 Techniques for addressing eating, weight and shape concern	312
	26.6.2.3 Techniques for working with eating disorders that do not have weight and shape concern at their core	316
	26.6.2.4 Working with the relationship with the clinician	318
	26.6.3 Preparation for the real world	320
	26.6.4 Recovery and relapse management	321
	26.6.4.1 Relapse management	321
	26.7 Endings	323
	26.7.1 A planned ending at the preagreed end of CBT	323
	26.7.2 A planned ending at the transition between child/adolescent and adult eating disorder services	325
	26.7.3 Ending in sub-optimal circumstances	326
	Summary	329

Section VII	Endings

27	What to do when CBT is ineffective	333

28	Recovery	334
	28.1 Defining recovery and the recovery process	334
	28.1.1 Cognitive factors: overevaluation of eating, shape and weight	335
	28.1.2 Emotional factors	335
	28.1.3 Behavioral change	336
	28.1.4 Physical factors	337
	28.1.5 Social factors	337
	28.1.6 Achieving goals	338
	28.1.7 Objective measures	338
	28.2 Applying recovery definitions to a heterogeneous population	338
	28.3 The stages of change model revisited	339
	28.4 Recovery as a process: using these models in the clinical setting	341
	28.5 Agents of change	341
	28.6 The patient's perspective on the recovery process	343
	28.7 What is not recovery (including identifying pseudo-recovery)	344
	28.8 Weight gain and obesity	344
	28.9 The clinician's perspective: knowing when to end treatment	345
	28.10 Summary	346

29	Relapse management and ending treatment	347
	29.1 Troubleshooting	348
	29.1.1 Patients who will not end	348
	29.1.2 When treatment has not worked	348
	29.2 Planning for further change	349
	29.3 Understanding, acceptance and management of risk	349
	29.4 Relapse prevention	349
	29.5 The final session	350
	Summary	351

	Conclusion: cognitive behavioral therapy for the eating disorders	353

	References	354

	Appendices
	1 Semi-structured interview protocol	365
	2 Psychoeducation resources	376
	3 Food diary	431
	4 Behavioral experiment sheet	433

	Index	435

Preface

This book is about the application of cognitive behavioral therapy (CBT) to the wide range of eating disorders. It is intended to be a clinician-oriented tool, useful in practice, rather than a comprehensive review of outcome studies (see below). It is based on the experience of a team who have a strong CBT philosophy, and who have spent a considerable time in working with patients to develop methods that are helpful in patient recovery. Those methods are based on a combination of:

existing CBT methods – taken from the broad CBT literature, as much as from the eating disorders literature

clinical suggestions from a range of sources

innovation from within our team.

We have not reviewed the evidence on treatment or on underlying pathology. There are many excellent reviews indicating that CBT is a powerful tool in the bulimic eating disorders (e.g., Fairburn & Harrison, 2003; National Institute for Clinical Excellence, 2004). These indicate that CBT is as good as any other psychological or pharmacological therapy for bulimia nervosa and binge eating disorder, and that it is the best therapy in many cases. However, those reviews also indicate that CBT has limitations. Even when it is applied thoroughly, many patients do not recover with this approach. Our experience suggests that there is a key set of problems in the use of CBT with the eating disorders:

It is often applied rigidly, focusing on protocols rather than the underlying cognitive-behavioral principles.

Most such protocols are designed for patients with bulimia nervosa or binge-eating disorder. There are fewer for anorexia nervosa, and almost none for the other atypical eating disorders (which form the largest number of cases – e.g., Fairburn & Harrison, 2003).

Most protocols do not describe what to do when there is significant comorbidity (e.g., concurrent anxiety disorders or personality disorder).

Many practitioners who suggest that they are using CBT are not doing so in any meaningful way. At the milder end of this problem, there are clinicians who are using protocols that are outdated; at the more severe end, there are practitioners who simply label their work as CBT, but do not appear to deliver a treatment that is recognizable as CBT (e.g., Tobin, 2005).

This book is intended for those who wish to use CBT in a way that can help a wide range of patients – both those with straightforward problems and those with more complex eating disorders and comorbid states. We also acknowledge that there will be a number of patients who are not able to use cognitive-behavioral treatments, often because they have more pressing needs for physical stabilization or because the patient is in a setting where CBT cannot be implemented.

Given the diversity of patient presentations, we do not believe that it is possible to develop a definitive protocol. Therefore, the book is based on cognitive behavioral principles, rather than presenting a protocol per se. There are certainly key cognitions and behaviors to be targeted and tasks to be achieved, and some need to be addressed before others. However, a firm grasp of the underlying principles will be the most important tool that the clinician can have in his or her toolbox. We will use case studies to illustrate this principle in action. In order to simplify the text, we have referred to patients as female throughout, in deference to the much higher number of females with eating disorders. However, this book is based on our experience of working with both females and males, and we apply the same principles regardless of patient gender. A further distinction to note is that we have generally referred to “clinicians” rather than “therapists” throughout. The distinction is an important one to us, since we adhere to the principle that “therapist” is a role rather than a person in CBT. To be truly successful, CBT requires the handing over of the “therapist” role from the clinician to the patient as the treatment proceeds. Otherwise, we find that change in the patient's condition is hard to achieve and is not maintained. It will also be noted that we use the term “patients” to describe the people with eating disorders, rather than “customers,” “clients” or “service users.” This term is used not because of adherence to any specific model, but because it reflects the language that these sufferers say that they prefer in clinical settings. Finally, we have assumed that the majority of this clinical work will take place in an outpatient setting, although that does not mean that we see CBT as being impossible to implement in day- and in-patient settings.

Before proceeding, we acknowledge our debt to the many clinicians who have inspired our work. However, we have been aided just as much by our patients, who have helped us though collaborating as cotherapists in their own treatment, working hard with us to come up with solutions.

Cognitive Behavioral Therapy for Eating Disorders

To our families.

Acknowledgments

Contents

Preface