The essence of cognitive therapy is to change these unhealthy beliefs into more flexible and realistic attitudes. Of course, patients may resist changing, since doing so may challenge the basic structure of their lives. One cause of resistance is known as symptomatic self-reinforcement.” In other words, if starving yourself makes you feel good about yourself, then that behavior may be hard to give up. Or the patient may resist because she doesn’t want to surrender the “guidelines for living” that she has established for herself. She must confront an onslaught of new feelings and experiences, but she lacks the “rulebook” that in the past told her how to respond.
Naturally, during this time the patient feels confused, frustrated, and frightened. Or she may shut down emotionally. Many patients who reach this phase of therapy tell me, “I just feel empty,” or, “I feel nothing at all.” Sometimes, as treatment takes effect, she encounters emotions she hasn’t felt in ages. She may want to interpret her sadness, anger, or depression as evidence that she is weak. In the past, she knew that such weakness would lead to a dietary catastrophe. In therapy, she learns that such emotions are part of daily life, and that she can learn how to handle them without falling back on her symptoms.
One way to change distorted thinking is through de-centering. In this strategy, I encourage the patient to think about the problem from another perspective, to remove herself from the center of the issue and try to evaluate things more objectively.
Here’s an example. A patient named Liz told me, “Everyone always watches me when I eat.” I asked her, “Do you always notice what other people eat?” “Of course not,” Liz answered, “Why should I?” By exploring this topic further, the patient eventually realized that, just like herself, other people are probably too wrapped up in their own concerns to spend much time noticing her. Liz learned that she was not the center of someone else’s universe-and found she was much happier with that thought.
Another way to counteract distorted thinking is through decatastrophizing. Let me explain. A patient might say, “If I don’t get that promotion at work, then my life won’t be worth living.” I might challenge this by exploring it further, saying, “What’s the worst that can happen?” or, “What can you do to make this situation better?” My goal is to help the patient take a more realistic view of the event, and to help her discover some of the alternatives open to her. When you are feeling depressed, it generally helps to be active rather than to sit passively and helplessly.
A similar approach works to counteract the “tyranny of the ‘Shoulds.’ “If the patient says she “should” do something-study harder, eat less-I will urge her to explore what would happen if she didn’t. Often, she begins to see that the dire consequences she had predicted would actually fail to materialize.
Through reattribution, the patient learns to interpret her experience more accurately. For example, an anorexic might feel that her excess energy is a sign of vitality and health, a vindication of her decision to starve herself. I will work to show her that extreme anxiety may result when the body is threatened with emaciation and that this can result in the need to be constantly active.
Another technique, developed by Christopher Fairburn, focuses on problem solving. In this strategy, the patient learns how to tackle problems in new and creative ways without resorting to bingeing.
First she must identify the problem precisely and come up with as many alternative solutions as possible. Say, for example, that her boyfriend breaks their date for Saturday night. Normally such a catastrophe would prompt her to binge. In therapy, though, we look at the other actions she might take: calling another friend, running errands she has been putting off, finishing a project, and so on. She then looks at each of these alternatives and decides which is the most practical and effective. After rehearsing the solution in her head, she carries it out. Later that day or the next, she reviews her decision and decides how well it worked, perhaps giving herself a grade on a scale of one to ten.
I ask patients to use their food-monitoring sheets to note these problems and how they came up with their solution. We can then review the process in therapy sessions. Doing so lessens the impact of problems. What’s more, it reduces the frequency with which problems occur.
I’ve mentioned just a few of the strategies of cognitive therapy. Regardless of the approach, the goal is to help the patient express her thoughts and to examine those thoughts from many different angles. We challenge her overly constricted ways of thinking and feeling. In the process, we help bring about a fundamental change in the way she perceives and interprets the world.
When we reach that goal, the patient finds herself equipped with a magnificent tool for fixing disordered eating: her mind.
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