Treating Bulimia Nervosa and Binge Eating

An Integrated Metacognitive and Cognitive Therapy Manual

Myra Cooper, Gillian Todd, Adrian Wells

• Publisher: Routledge
• Year: 2008
• ISBN:
  9781135444655
• Edition: 1
• Topic: Psychologie
• Subtopic: Psychopathologie

Treating Bulimia Nervosa and Binge Eating explains how cognitive therapy can be used to treat those suffering from bulimia nervosa. The manual provides a step-by-step treatment guide, incorporating a number of case examples offering detailed explanations of the treatment process, questionnaires, worksheets and practical exercises for the client, which will provide a framework and focus for therapy. The authors use existing techniques, as well as new integrated cognitive and metacognitive methods developed from their recent research, to take the therapist from initial assessment to the end of treatment and beyond, with chapters covering:

• engagement and motivation
• case formulation and socialisation
• detached mindfulness strategies
• positive and negative beliefs.

This practical guide will allow those treating patients with bulimia nervosa to take advantage of recent developments in the field and will be an essential tool for all therapists working with this eating disorder.

CHAPTER 1
Introduction to the book, a case example and an overview of treatment

This chapter begins with guidance on how to use the book, and discussion of who might benefit from the treatment. It introduces the reader to the symptoms and treatment of bulimia nervosa (BN) by presenting a case example of a patient (Jessica) with the disorder. It highlights the symptoms and problems that she experienced in relation to her illness, and then provides a detailed description of how her treatment with our version of cognitive therapy proceeded, as outlined in more detail in the remaining chapters of the book. It includes general information (for example, about the format of sessions) as well as a session-by-session summary of the course and content of the specific treatment received by Jessica. The treatment described here is a synthesis of our earlier work on the cognitive theory of BN (Cooper et al. 2004) with metacognitive therapy of psychological disorders (Wells 2000). We will continue to use the term cognitive therapy in this book for simplicity but we increasingly find ourselves moving towards a metacognitively focused approach.

INTRODUCTION TO THE BOOK

The book is designed to be used as a guide for therapists working with people with BN. It provides a structure, framework and focus for therapy. The book is written with individual therapy in mind, and provides a step-by-step guide from initial assessment to the end of treatment and beyond. The worksheets and patient information sheets are an important part of treatment, and therapists should aim to make maximum use of these, in addition to the advice and suggestions in the text.

Who can use the book?

All suitably trained therapists, from a range of professional backgrounds, should find this book useful. As with all psychological therapies, and problems treated, therapists must seek appropriate supervision and adhere to their professional code of ethics when using the programme.

Is the book just for bulima nervosa ?

The treatment is based on new developments in our understanding of eating disorders. These are not confined to BN, and belief is that the book is also helpful for those who present with a range of binge eating problems, including Sub-clinical BN, or variations of eating disorder not otherwise specified (ED-NOS), in which binge eating is a major problem. The experts do not agree on what the current diagnostic categories in eating disorders should be (e.g. Fairburn et al. 2003; Keel et al. 2004). In our work we have focused on conceptualising and explaining the symptoms of eating disorders, while at the same time juggling the complexities of the diagnostic categories used. Our experience is that the treatment will be useful to those with a range of binge eating disorders. We also have some exprience of research into this group (e.g. Cooper et al. 2007a). Nevertheless, it is important to note that this group, and ED-NOS in general, has not been widely studied.

What about those with low weight?

Those with anorexia nervosa (AN) may experience binge eating, and some of these people will be on the border between AN and BN. We discuss low weight AN with binge eating further in Chapter 2. The treatment has not been developed on those with low weight who also binge eat, although there are many transferable strategies that can be used in this book, provided due attention is paid to the speci®c problems of low weight.

What about adolescents?

Bulimia nervosa is not confined to adults, and many adolescents are now seeking treatment. Some of our research has involved adolescents (e.g. Rose et al. 2006), and our view is that the model and treatment is applicable to this group. Our experience is that adolescents value the experience of individual treatment in this format, and much prefer it to the family focused treatments they have sometimes previously received. Nevertheless, there are inevitably systemic and developmental issues that arise and themes based on these topics may be an integral part of the problem. It is important to have some awareness of the normal developmental tasks of adolescence, and while this should be routine for those who have experience with adolescents, those who work mostly with adults with BN may need advice if seeking to treat adolescents, particularly those who are younger, with this programme.

In the remainder of the chapter we describe a case, Jessica, and her progress through the programme outlined in later chapters.

A CASE DESCRIPTION—JESSICA

Jessica was referred to Mental Health Services by her family physician for psychological treatment of her bulimia nervosa. She was aged 26, and had not had any previous psychiatric or psychological treatment. When seen for an initial assessment she said that her eating was ‘out of control’ and that she was obsessed with thinking about food and her figure. Every day she would plan to eat what she considered to be a healthy diet that had an upper limit of 1,000 calories, and would start off with good intentions. However, she would end up eating ‘junk food’ and then feel guilty and worried about gaining weight, having broken one of her dietary rules. This was followed by binge eating, which she felt was uncontrollable. She perceived herself as fat although her Body Mass Index (BMI=weight (in kilograms)/height (in metres)) fell within a normal range, and she reported feeling self-conscious about her weight and shape. In particular she felt disgusted by the shape of her stomach and thighs, which she saw as flabby and disproportionate to the rest of her body.

Jessica was constantly striving to lose weight because she believed that achieving her desired shape would make her feel happy, and confident to do things that she currently felt unable to do. Consequently she would set herself unrealistic targets for weight loss by trying ‘lose weight quick diets’ found in women’s magazines, e.g. to lose 4kg in a week, or drop a dress size, even though she knew these diets were ineffective. Her rigid rules for dieting were unsustainable and she despaired of ever achieving significant weight loss because she frequently binged. She was miserable about her weight and eating habits, and often felt quite depressed. She said:

I’m tired of getting so wound up about it all, I think about food and how I look all the time. Sometimes I think I’m going mad. I just want it all to go away. I can’t carry on living like this—it’s not a life. I want children, but I can’t even cope with myself.

Her eating was erratic—she missed meals during the day to try and keep her calorie intake down, drank copious amounts of water to suppress her appetite and chewed gum obsessively so that she wouldn’t be tempted to eat. She described binge eating at least once a day, and most of the time this was followed by self-induced vomiting in order to try to control the extreme distress she felt about her weight and shape, including great fear of gaining weight and getting fat, which always followed episodes of binge eating. She felt embarrassed and ashamed disclosing this information.

In a typical week Jessica would have eight to ten binges—usually when she returned home from work before her partner came home, and occasionally during her lunch break at work. Jessica had thought a great deal about why she binged, and recognised that at least some of her binges occurred as a way of coping with negative emotions such as worry, anxiety or sadness, rather than any overwhelming hunger. She felt frustrated by this, and described times when she repeatedly asked herself, `Why am I doing this to myself?’

A typical binge consisted of several packets of crisps or savoury snacks (typically around five in total), four or five pastries, two or three packets of chocolate biscuits, several rounds of toast spread with butter, and two to three small chocolate bars or a tub of vanilla ice cream. Jessica also considered eating a ‘forbidden’ or ‘bad’ food, which could be a small amount, for example, one 25g chocolate bar, as bingeing. After bingeing Jessica would feel concerned about the impact of bingeing on gaining weight and would compensate for this by inducing vomiting as a means of getting rid of the calories and controlling her weight. On occasions, if she felt particularly fat, she would take 8–10 laxatives in addition to vomiting. She also followed a rigid exercise regime.

Jessica described having been worried about her weight and shape since her teenage years. She went through puberty before most of her peer group and recalled feeling self-conscious of her body shape and size in relation to others. She was concerned that other people perceived her as fat. She recalled a situation when a group of boys in the schoolyard said that they knew her name, F.A.T., and then burst into fits of laughter. She hated the way she looked and would try and conceal her body shape through wearing baggy clothes. Her mother, who also had issues with her own weight and was always following the latest diet fad, used to feed Jessica salads, and encourage her to eat less, while her siblings were offered family meals of normal size and more varied content. Her two older brothers referred to her as ‘blubber’ and would make ‘fat’ jokes, which everyone in the family found amusing. A friend told Jessica that vomiting was good for losing weight and she started to induce vomiting after normal eating. At first she would drink salt water or push a toothbrush to the back of her throat to stimulate the gag reflex and vomit. Later she could vomit spontaneously. Initially she lost weight, and everyone said how good she looked, which increased her sense of self worth. However, the belief that she could eat what she wanted if she induced vomiting and not gain weight encouraged her to use eating to reduce emotional distress, and bingeing and vomiting quickly became a way of life, that is, a way to manage and deal with emotional distress.

Jessica had a boyfriend with whom she had been living for about 8 months. Although he knew about her problem, Jessica said that he ‘pretends it doesn’t exist’, and added that he was unaware of just how chaotic her eating was and, among other things, how much she typically ate in a binge. She expressed doubts about their future together, and also described feeling stressed in her job, which involved managing a small administrative team.

JESSICA’S TREATMENT

Jessica had 16 individual cognitive therapy (CT) treatment sessions, following the programme outlined here, over a period of five months. Each session followed a similar format, as detailed below.

A typical session format

At the beginning of each CT session Jessica completed the Eating Disorder Rating Scale (EDRS), a measure of key cognitions and behaviours relevant to BN and to the treatment model. (Questions included information on the frequency of behavioural symptoms, including bingeing, use of exercise to lose weight or prevent weight gain, and degree of belief in key cognitions relevant to the model, for example, related to negative and positive beliefs.) This provided an immediate indication of progress in changing important symptoms, and in changing the key thoughts relevant to the model on which treatment is based. The EDRS also provided a focus for the session; for example, it highlighted key thoughts and beliefs that were not changing or that might need to change for symptoms to decrease further. A copy of the EDRS can be seen in Appendix 1: Eating Disorder Rating Scale.

The format of the sessions followed a standard cognitive therapy protocol, similar to that described in detail elsewhere (Beck 1995). In brief, at the start of each session, the preceding week or time since the last session was reviewed, using the Weekly Evaluation Sheet, which she had completed prior to the session. This provided an opportunity for a personal review of the week. It indicated any progress she felt that she had made since last time, and highlighted any problems and difficulties she had experienced. There was also an opportunity for reflection on what she had learned. A copy of the Weekly Evaluation Sheet is displayed in Appendix 2. An example of a completed sheet can be seen in the box overleaf.

Homework assignments or tasks (a regular feature of treatment) were reviewed, and any further points for discussion were identified. An agenda for the session was set collaboratively, with both Jessica and her therapist contributing items. In the earlier sessions Jessica was unsure what to contribute to the agenda and the therapist took the lead in suggesting items. As sessions progressed Jessica became much more involved, and increasingly volunteered her own ideas. After setting the agenda the session moved on to tackle the specific items listed on it in some detail. Care was taken to ensure that a manageable number of items were identified for discussion, and that time was allocated in the most useful way. If necessary, items were prioritised, assigned as homework tasks and, also if necessary, deferred to the next session. Finally, further homework, based on the session’s discussion, and including any findings from the previous week’s homework, was decided upon by Jessica and her therapist together. The session concluded with the therapist eliciting any feedback and comments that Jessica had on the session. She was asked to comment, for example, on what had been helpful and what had not been so helpful or what had been difficult. Each session was audiotaped, and Jessica took an audiotape of the session away with her. Listening to the audiotape for homework was always recommended, sometimes with a specific aim identified in the session, but also to encourage learning, reflection and feedback to the therapist at the next meeting. At first Jessica commented that she hated the sound of her own voice and felt embarrassed hearing some of the things she had discussed. This made listening to the audiotape recording of the session difficult for her, although after persevering with the task she ultimately found it invaluable.

WEEKLY EVALUATION SHEET

Date: 17 October

What have I achieved this week?

I managed to not binge and vomit for 2 days through using the binge postponement strategy. I told my family about my bulimia and they were cool about it. My Mum asked me to ask you if there is anything she should be doing to help.

What have I learned?

I felt really pleased with myself and thought that I can crack the bulimia.

I was surprised Mum was so keen to help.

What has been difficult for me?

The other 5 days I binged and vomited between 2 and 5 times a day, which is rubbish. Working the late shift at the supermarket always gets to me. When everyone has left for work I binge my head off, because I can. I don’t know why I do it, I just do it. It’s so easy, like a bad habit that I’ve had for years. I just want to get rid of the bulimia and feel fed up with it ruining my life. I’m so worried that I’ll get fat and have to think about what I’m eating to stop that from happening. It’s exhausting.

What areas do I need to work on over the next week?

Stopping bingeing, I need more strategies. I also need to know why I keep on doing it. I’m a young woman and should be thinking about other things that are more important like going out and having fun.

What realistic, achievable goals can I set myself ?

Try to cut down bingeing, especially in the mornings.

What problems am I likely to have?

It’s hard to be on my own at home. There is so much ...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Acknowledgements and an introductory note
• 1 Introduction to the book, a case example and an overview of treatment
• 2 Diagnosis and assessment
• 3 Treatment of bulimia nervosa
• 4 A new cognitive model of bulimia nervosa
• 5 Engagement and motivation
• 6 Case formulation and socialisation
• 7 Detached mindfulness strategies
• 8 Negative beliefs about eating: uncontrollability and consequences
• 9 Positive beliefs about eating
• 10 Negative self beliefs
• 11 Ending therapy
• Therapist resources
• Blank worksheets
• References