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Section 19
Cognitive Behavior Therapy in Treating Bulimia Nervosa:
A Case Study

Question 19 | Test | Table of Contents

ABC theory of emotional disturbance
The ABC theory of emotional disturbance is one of the important concepts in cognitive behavior therapy (CBT). "A" is known as an activating event or the existence of a situation. "C" is the emotional and behavioral consequence or reaction of the individual. According to the theory of cognitive behavior therapy, A (the activating event) does not cause C (the emotional and behavioral consequence). It is B (the person"s interpretations of, and assumptions about A) that is largely responsible for C, the emotional and behavioral reactions.

In bulimia nervosa, the emotional "baggage" such as anxiety, guilt, anger, etc. and various practices that help to prevent weight gain and the change of body shape are the consequences (C) of the client"s interpretations of and assumptions about (B) an activating event (A). The activating event, for example, could be that the client has broken her dietary rules or that the client has put on some weight. Fairburn (1997) points out that these thoughts are largely the result of the way the bulimic interprets the assumptions made about the breaking of her dietary rules or putting on some weight. It is therefore important for the therapist and the client to work collaboratively to target what overvalued thoughts (negative self-beliefs and rules) are causal to the bulimic symptoms. Using a vignette as an example, the remainder of this paper will illustrate how to target the specific content of thoughts, and inform the conceptual and practical issues underpinning a range of evidence-based techniques. These techniques will facilitate the change at both levels of cognitions and behaviors.

The vignette: the client
Rachel was an attractive and intelligent woman in her early 30s. Her General Practitioner"s referral indicated that she was suffering from symptoms characteristic of bulimia nervosa: self-induced vomiting, over-exercising, and laxative misuse. She strictly restricted her food intake and was therefore under continuous pressure to eat. It was the form of her dieting that made her particularly prone to eat.

She described herself as a reasonably successful person, working for a large international company that required her to travel extensively abroad. She set herself extremely high standards and was profoundly dissatisfied when she did not meet them. This perfectionism was seen in many aspects of her life, and it was applied to her dieting thereby accounting for its intensity. She described herself as a sensitive person who needed to be accepted by "virtually" everybody in order to feel secure in herself. Other identified problems were low self-esteem and non-assertiveness.

Cognitive assessment: a binge-purge situation
Following a business meeting in a restaurant, Rachel was anxious and believed that she had eaten "too much". In addition to the anxiety, she was angry with herself for losing control in her dietary intake and felt guilty about it. Subsequently, she reduced her food intake for the next few days, used laxatives and increased her frequency of exercising. Using the ABC model, the process of cognitive assessment is illustrated (T = therapist, C = client):

T: What was so anxious-provoking in your mind about "eating too much" in the restaurant?
C: I don"t want to.
T: I know you don"t want to, but what was going through your mind when you believed that you had too much to eat?
C: I will be fat.
T: Suppose, let me just suppose that you are fat, then what?
C: Ugly.
T: What if you are ugly?
C: I don"t like to be ugly.
T: I wonder why?
C: That means I am losing control, and I don"t want that to happen.
T: What will it mean to you about losing control?
C: I will not be liked by people, if that is the case.
T: People! Who are these people?
C: Everybody.
T: Suppose it is true that everybody doesn"t like you, what then?
C: I must be liked; I must not be rejected by people.
T: What will it mean to you if you are not liked and are rejected by people?
C: That will be terrible and I am no good and unlovable then.

Rachel"s need to take dietary control seemed to be more related to the evaluated beliefs of rejection, awfulizing and self-worth. People who have inferred beliefs such as fat, ugly and disliked by people do not necessarily end up with bulimia nervosa. Dryden (1995) concludes that inferred beliefs contribute to, but do not determine emotions. Evaluative beliefs, on the other hand, cause both intense emotional and behavioral reactions to negative events (Safran et al., 1986; Ellis, 1994) and may undermine the client"s motivation or sense of adequacy or self-worth (Beck, 1995; Fennell, 1999).

Greenberger and Padesky (1995) suggest that it is important to identify and examine them so as to facilitate sustainable emotional and behavioral changes. Barton (2000) presents an argument that it is important to differentiate between negative (inferred beliefs) and depressive thinking (evaluative beliefs) in relation to depression. For example, negative thoughts or inferred beliefs such as "I am not much good at sport"; "The world is facing difficult social problems"; "Next week is going to be really stressful" clearly will not cause depression. Cognitive behavior therapists that inadvertently challenge thoughts or inferred beliefs that are less central (or unrelated) to depression will result in little therapeutic gain. Similarly, challenging thoughts or inferred beliefs that are less central to bulimia nervosa will at best provide some symptoms relief and at worst prolong suffering or increase the likelihood of relapse or recurrence. For example, helping the bulimic to recognize (or even to accept) that she is neither fat nor ugly can result in a little therapeutic gain.

The intensity and rigidity of the dieting seen in Rachel could be understood as an expression of the combined influence of two general cognitive characteristics, perfectionism and dichotomous thinking (thinking in black and white terms). According to Fairburn (1997,p. 212), "patients with bulimia nervosa tend to be perfectionist by nature. This perfectionism is seen in many aspects of their life, and it is applied to their dieting, thereby accounting for its intensity". They set themselves extremely high standards and are profoundly dissatisfied when they do not meet them. This important point is highly relevant to the therapeutic work with bulimia nervosa. Perfectionism is rigid by nature and is often expressed in the form of "must", "should", "have to" and "ought to". Rigidity is the source of psychological and emotional problems (Ellis, 1994). They overestimate how bad it is when expectations are not met, and this leads to emotional distress such as anger, anxiety and guilt (Bums, 1990).

In the case of Rachel, her perfectionism was, "I must be able to be in control of my food intake"; "I should be able to cope and do well in my job"; "people ought to appreciate and praise my achievements"; "my house has to be clean and spotless". Her dichotomous thinking was -- "if I lose dietary control, I will be rejected by others"; "If I am rejected by others, it will be terrible and I am no good and unlovable". In order not to be rejected by others and to feel worthy as a person, Rachel was trying hard to be perfect in many aspects of her life, including her food intake. The combined influences of perfectionism and dichotomous thinking were found to be consistent in her cognition in other situations, from work, social and domestic chores. It was the fear of rejection or being disliked and being worthless that was driving her to set herself extremely high standards in many aspects of her life, including her diet. Targeting thoughts relating to rejection, sense of self worth and awfulizing are likely to result in better treatment outcomes. Figure 2 illustrates the cognitive behavioral conceptualization in the maintenance of bulimia nervosa.

Disputing dysfunctional thoughts: rejection, self-worth and awfulizing
These dysfunctional thoughts, often expressed in the combined influence of perfectionism and dichotomous thinking (Fairburn, 1997), play an important role in the maintenance of the client"s problems. Better treatment outcomes require a therapeutic approach that initially focuses on empirically validating the rationality and logic of these thoughts. Once the client is able to recognize and accept that these thoughts are irrational and illogical, it will help to increase the level of compliance with the therapeutic tasks such as homework and the self-monitoring of treatment progress. For example, the client may agree to a therapeutic task that requires her to "temporarily" change her body image and her eating habits/pattern. This empirical test will enable her to find out if rejection could be the result of (or the change in) body shape and weight.

Rejection and self-worth
The fear of or anxiety about rejection is often expressed in the form of "must" and "should" statements. For example, "I mustn"t be rejected by everybody", "People shouldn"t reject me. Otherwise, I am unlovable and no good". This form of rigid expression can lead to a range of emotions such as anger, guilt and anxiety (Burns, 1990), reduce the client"s self-worth (Fennell, 1999), and help to maintain the client"s problems. Ellis (1994) believes that rigidity is the source of psychological and emotional problems.

Rational and pragmatic arguments are useful in helping the client to give up the dichotomous thinking about rejection (Ellis, 1994; Dryden, 1995). Rational arguments help the client to understand that rejection (or being disliked by some people) is the experience of every fallible human being. There is no law of the universe to say that just because people don"t like it, it mustn"t happen. Rejection happens to people at different times in their lives. It is important to note that the rational disputing itself is not about empirically evaluating the evidence that the client might have but on whether this kind of dysfunctional thinking ("must" and "should" statement, dichotomous thinking) is rational or not. Pragmatic arguments, on the other hand, are to draw the client"s attention to the consequences of holding on to the dysfunctional thinking. It is a supplement to the rational argument. The client often is not consciously aware of the implications of holding on to the dysfunctional thinking. The implications can be related to his/her personal life, health status, work performance and interpersonal relationships (Fairburn et al., 1993). The following therapist/client dialogue illustrates the rational and pragmatic arguments. This came from the author"s clinical work (T = therapist, C = client):

T: Why mustn"t people reject you?
C: I don"t want to.
T: That"s your preference, but is it rational to say just because you don"t want to, people (or some people) mustn"t or shouldn"t reject you?
C: Well, I suppose not, but it is terrible and awful to be rejected.
T: Let"s assume that it is terrible and awful to be rejected. I wonder whether there is any law of the universe to say that just because you feel terrible and awful and you don"t like it, then people mustn"t reject you?
C: Yeah, well, there is no law to say that.
T: OK If there is no law to say that, then why mustn"t people reject you?
C: I suppose not.
T: Because of?
C: Well, I have no control over what they think and do.
T: Absolutely. Suppose that your beloved daughter came to you saying that she was no good and a failure if people rejected her. Do you think that she is?
C: Of course she is not.
T: Why not?
C: She can"t be a failure or not good just because of people (or some people) rejecting her.
T: Good, Help me to understand that why if she is not a failure and is not no good, you are?
C: Oh, I see. I operate on two rules: one is for my daughter and the other for myself.
T: Is it helping you to do that?
C: Not, it is not.
T: If that is the case, how is it helping you to hold on to the thought that you mustn"t be rejected by people or you are a failure and no good?
C: It hasn"t been helping me. I can see that now.
T: Is it possible for a person to be either loved or rejected by everybody?
C: Oh, well. I suppose not.

Two important concepts are illustrated in these rational and pragmatic dialogues. The first is about internal versus external locus of control. Dyer (1992,p. 149) states that "the internal locus of control person puts the responsibility for how he/she feels squarely on his/her own shoulders", whereas the "external person" assigns responsibility of his/her emotions to someone or something. Emotions or feelings are the result of how and what the person perceives himself/herself in relation to the others. Distinguishing the differences between internal and external control may help the client to take on the responsibility for his/her emotions and to question his/her thoughts about self-worth. This could raise his/her motivation and self-confidence in the change process.

The second concept is about the use of two sets of rules that the client practices: one is for herself and the other for her daughter. Lam (1997,p. 1206) suggests that an effective strategy is to shift the client"s thinking into a state of objectivity in which not only is disputing effective but also helps the client to develop a higher level of abstract thinking which he/she could relate to his/her personal experience/problem. The "daughter"s technique" helped to psychologically move Rachel away from her dysfunctional thinking (she will be no good and a failure if rejected or disliked) into a state of objectivity relating to her daughter"s problem. This helped to facilitate the development of objective and rational thinking, which would act as a catalyst to reflect on the irrationality of her dysfunctional thinking.

Awfulizing
Referring back to the earlier example, Rachel believed that it was awful (or terrible) to be rejected or disliked by others. Engaging and believing this thought is problematic in a number of ways. First, the client is likely to see a situation in only two categories instead of on a continuum. For example, "if people reject me, it will be awful (or terrible)". "Unless I am liked or and accepted by others, otherwise it is awful". Second, emotional responses to these thoughts could be intense and enduring. As discussed earlier, the client tends to assign responsibility for his/her emotions to someone or something external to him/her, leaving himself/herself vulnerable to people"s reactions and opinions. Rachel"s emotions, for example, tended to fluctuate according to how people react towards her. Third, the client may engage in a whole range of behaviors intended to seek acceptance from people: from dieting, perfectionism to approval-seeking behaviors. This, in turn, will help to maintain his/her psychological difficulties and problems.

Beck (1995,p. 158) suggests that "a cognitive continuum technique is often useful with clients displaying dichotomous thinking". This technique is effective not only in modifying the beliefs that reflect polarized thinking but also in facilitating the recognition of the middle ground. The following dialogue illustrates the use of this technique:

T: How strongly do you believe that it is awful (or terrible) to be rejected by others? -- 100% is the most awful and 0% is not awful at all.
C: Well, a lot.
T: Okay, what is a lot? -- 100%, 80%, 60% or 40%.
C: I guess 90 100%.
T: I wonder whether there could be anything more awful (or terrible) than being rejected?
C: Ummm May be loss of my job. My job is important to me.
T: Well, how awful is it to lose your job?
C: Around 100%, I guess.
T: Okay, now if we put lost your job at 100% where does that put rejection, in a relative term?
C: 70-80%, I suppose.
T: Now, how about if your house burnt down and you had forgotten to renew your insurance?
C: That is an awful thing to happen.
T: How awful?
C: I guess it has to be 100%.
T: Now, where does that put job lost and rejection, in a relative term?
C: Probably around 80% (job loss) and 50-60% (rejection).
T: Could there be anything more awful (or terrible) than the house burning down without insurance?
C: Well, I suppose that something bad happened to my family.
T: Okay, let"s suppose that your daughter who you love very much was in hospital critically ill, how awful is it?
C: That is really awful.
T: How awful is it?
C: Well, definitely 100%.
T: Okay, Where does that put the others on the scale house burning down without insurance, job lost and rejection -- in a relative scale?
C: Oh, well. Around 70% (house burnt down), 50% (job lost) and 20-30% (rejection).
T: In that case, is it really awful (20 30%) to be rejected by people (some people)?
C: Not really, when it is put into context.

Working on behavioral change
There is both a close relationship and specific interaction between overvalued thoughts that are causal to bulimia nervosa and behaviors that help to maintain body shape/image and seek acceptance from others. Returning to Rachel, this paper hypothesizes that her core beliefs of rejection and awfulizing were the underlying causes of her binge eating and purging, perfectionism and approval seeking behaviors. This collection of behaviors cause distress and reduce self-esteem (Wilson, 1996), inevitably lead to more dietary restraint and binge eating (Fairburn et al., 1993) and prevent disconfirmation of threat-related cognitions (Salkovskis, 1991). Changes are, therefore, likely to be sustainable with interventions targeted at both the levels of cognitions and behaviors (Lam and Cheng, 1998).

Collaboratively, an experiment was devised in which Rachel was going to change her eating habits/pattern, put on an agreed amount of weight (6 pounds) and dress "suitably" for work with no make-up (she always dressed immaculately). This evidence collecting experiment was to test the hypothesis (Rachel"s belief) that the change in body image/weight would lead to being disliked and rejection. Lam and Cheng (1998,p. 1148) argue that "a homework assignment, in a form that was linked to the session, serves as a mechanism in facilitating the client to think about his/her thinking (overvalued)". What is important in this experiment is the need for the client to recognize and accept the rationale, and understand that "dietary control" is not going to be taken away from her. Fairburn and Walsh (1995) state that bulimic"s need to have strict control over their eating. Losing control can be interpreted as a threat to their self-worth. Recognizing and accepting the rationale for the experiment, together with the reassurance that dietary intake is still in their control, will help to increase the level of compliance with the agreed therapeutic tasks.

Initially feeling surprised at her 3-week findings that many of her colleagues and friends had hardly changed their behavior towards her, the realization that the change in body weight and image did not result in rejection, had brought a sense of relief to Rachel. This process of collecting evidence was enhancing Rachel"s conscious awareness that her overvalued thought was not only distorted and unhelpful but was also not based on fact. This would increase her confidence to agree to a stable pattern of regular eating and to be more flexible in the type of food she ate, thus helping to eliminate the need for binge eating. Fairburn (1999) believes that replacing binge eating with a stable pattern of regular eating is one of the major aims in the treatment process.

Overholser (1993) suggests the use of systematic questioning to help the client benefit from this exposure or experiment. For example, "What do you think you have learnt from this exercise? "What conclusion can you draw from your observation of peoples" behavior?"; "How is it logical to say that just because of the change in your body weight/image people will reject you?"; this type of questioning could cultivate a more reality based thinking, thus facilitating more effective problem solving strategies.

In bulimia nervosa, working on the client"s perfectionism and approval seeking behavior is essential and is an important aspect of the therapeutic change. The client often believes that unless things are performed perfectly he/she is no good or a failure; and that if his/her behavior is not recognized and praised by others then he/she is not a lovable and competent person. Failing to meet these expectations (or to have their expectations met) not only affects his/her self-worth but also generates intense emotional and behavioral reactions (Fairburn et al., 1993; Beck, 1995). Techniques that are found to be clinically effective in working on perfectionism and approval-seeking behaviors include cost and benefits analysis, assertive training, role-play and stress inoculation training, etc.

Discussion
The binge-purge frequency is often taken as a main target for intervention because of its status as a seemingly "objective" and quantifiable measure. However, treating primarily the symptoms and the inferred thoughts (e.g., I"m fat and ugly) associated with body shape and weight may not bring about sustainable changes. Mitchell et al. (1986) describe bulimia as a condition "which often remits spontaneously" and there is a general consensus that this disorder is difficult to treat (Russell, 1979; Fairburn, 1981).

The suggestion to initially target the overvalued thoughts (negative self-beliefs and rules) that are causal to bulimia nervosa is clinically important. Tiffs would ensure better treatment outcomes. Cooper et al. (1998,p. 228) believe that "for treatment to be successful and to prevent relapse it may be important to address both negative self-beliefs and underlying assumptions". This paper proposes that using a recent binge-purge situation as a "baseline" will help to identify these overvalued thoughts. Using the identified thoughts from the baseline, the therapist and the client can look for any consistencies in the client"s overvalued thoughts (negative self-beliefs and rules) in other situations. These situations could be work, social and/or interpersonal. Returning to Rachel, her overvalued thoughts (rejection, unlovable and awfulizing) were found to be consistent in a range of situations. These greatly affected her sense of self-worth and propelled her to strict dietary control, perfectionism and approval seeking behaviors.

Once the client is able to understand and accept that these overvalued thoughts are central to her psychological problems, in a range of other situations and not just associated with diet, this will provide her with the confidence and motivation to try to empirically validate these thoughts. This would further shift her overvalued thoughts, as her "observation or the data collected" has failed to support her thoughts about the personal implications of body weight and shape. The recognition that it is not awful or terrible to be rejected or unloved is an added incentive for the client to continue testing out whether or not rejection is the result of the change in body weight/image. This will help the client to understand that there is an array of contributing factors to a person being rejected (or unloved), not just body weight/image. The suggestion is that the role of behavior in the maintenance of psychological difficulties and problems is also clinically important. Behavioral changes should, therefore, go beyond just helping the client to adopt a stable pattern of regular eating. Assertive and social skills training and work on perfectionism will also help to modify the client"s negative self-beliefs and underlying assumptions (rules).

The process of behavioral changes (conducting the empirical study/experiments) itself not only helps the client to collect evidence/data to validate these thoughts but also helps him/her to integrate, synthesize and evaluate different sources of information. These skills will be invaluable in helping the client differentiate thoughts (overvalued thoughts) from the facts.
- Lam, Danny; Cognitive behavioral therapy to treating bulimia nervosa: a case study; Counseling Psychology Quarterly; Mar 2001; Vol. 14; Issue 1.

Personal Reflection Exercise #5
The preceding section contained information about a case study on cognitive behavioral therapy with bulimia nervosa.   Write three case study examples regarding how you might use the content of this section in your practice.

Update
Brief Group Cognitive-Behavioral Therapy
for Bulimia Nervosa and Binge-Eating Disorder:
A Pilot Study of Feasibility and Acceptability

Moore, E., & Waller, G. (2023). Brief group cognitive-behavioral therapy for bulimia nervosa and binge-eating disorder: A pilot study of feasibility and acceptability. The International journal of eating disorders, 56(6), 1228–1232.

Peer-Reviewed Journal Article References:
Fitzpatrick, S., MacDonald, D. E., McFarlane, T., & Trottier, K. (2019). An experimental comparison of emotion regulation strategies for reducing acute distress in individuals with eating disorders. Canadian Journal of Behavioural Science / Revue canadienne des sciences du comportement, 51(2), 90–99.

Lowe, M. R., Marmorstein, N., Iacono, W., Rosenbaum, D., Espel-Huynh, H., Muratore, A. F., Lantz, E. L., & Zhang, F. (2019). Body concerns and BMI as predictors of disordered eating and body mass in girls: An 18-year longitudinal investigation. Journal of Abnormal Psychology, 128(1), 32–43.

Pearl, R. L., Wadden, T. A., Bach, C., Gruber, K., Leonard, S., Walsh, O. A., Tronieri, J. S., & Berkowitz, R. I. (2020). Effects of a cognitive-behavioral intervention targeting weight stigma: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 88(5), 470–480.

QUESTION 19
Beck suggests that a cognitive continuum technique is often useful with clients displaying dichotomous thinking. What are the benefits of a cognitive continuum technique? To select and enter your answer go to Test.

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