Bulimia Therapy Online
The cognitive-behavioural theory of bulimia nervosa
The cognitive-behavioural model of maintenance of bulimia nervosa indicates that the main cognitive disturbance and the key element that perpetuates the disorder is the excessive evaluation of eating, shape and weight, and their control. People with this eating disorder judge their self-worth almost exclusively by their weight and shape. This evaluation comprises weight control behaviour (vomiting, diuretics and laxatives misuse, excessive exercise, and dietary restraint) and the constant worry thoughts about eating, food, shape and weight. Other clinical characteristics can be seen as secondary to this.
The only clinical feature that is not directly linked to the overvaluation of eating, shape and weight is binge eating. The cognitive-behavioural model suggests that binge eating is the result of the person’s dietary restraint. People with bulimia nervosa have multiple, extreme, and hard-to-achieve rules about food.
Fairburn (2002) proposes that these demanding rules are an expression of perfectionism, and include when they can eat, what they should eat, and the overall amount of food they allow themselves to have. Following all these rules tends to be very difficult, and people usually end up breaking them, which tends to trigger a negative reaction in the person. Even a minor rule slip is seen as evidence of their lack of self-control and failure. This black-and-white thinking, where the only option is to follow the rules or break them all, typically leads to temporarily abandoning the efforts to restrict food. This is a major trigger of binge eating. In consequence, a particular pattern of eating develops, where extreme rules and restrictions are interrupted by repeated episodes of binge eating.
These binges perpetuate the main cognitive disturbance by amplifying people’s concerns about their capacity to control food, shape, and weight. As such, this reinforces the need to restrict food and increases the probability of further binge eating.
Binge eating usually happens when the person has a negative mood, as these moods tend to reduce the capacity to control their eating. Moreover, food can reduce these negative emotional states and it becomes a short-term reward that leads to the formation of an unhelpful coping mechanism. In other words, binge eating occurs for two reasons: first, because of the hunger caused by food restriction, and second because it reduces unpleasant emotions.
A further vicious circle is developed with the use of compensatory purging methods (vomiting, laxatives, and diuretics). People with bulimia erroneously think that purging will decrease the risk of weight gain after binge eating, and this eliminates an impediment against binge eating.
Implications of this model
This theory indicates that treatment should focus on binge eating, but also dieting and the excessive evaluation of eating, shape, and weight, and their control.
CBT treatment for bulimia
Cognitive-behavioural therapy (CBT) is the recommendable treatment for bulimia nervosa. Fairburn (2002) explains that the treatment has three overlapping and evolving stages:
This stage has three main objectives:
- Explain to the person the cognitive-behavioural model of bulimia and the rationale underlying the treatment. Specifically, explain why it is needed to focus on binge eating but also dieting and the excessive value of eating, shape, weight, and its control.
- Psychoeducation to understand bulimia nervosa and address mistaken beliefs about dietary restraint and weight control.
- Meal planning: Help to start regaining control over eating by acquiring a pattern of regular eating. This includes exposure to forbidden foods and challenging dietary rules.
In stage two, the aims are:
- Continue eating regularly.
- Address dieting in general.
- Tackle over-evaluation of shape and weight and the behaviours that perpetuate the concern (e.g., checking areas of the body or avoiding looking at oneself in the mirror). Here you can read more about tools to overcome negative body image.
Although this is the guideline, external events might require expanding the aims of the therapy and extending the therapy in length to address any additional problem that might arise.
In the last stage, the therapist and client plan together how to maintain progress in the future and how to deal with relapse and setbacks.