Therapy for Eating Disorders: Theory, Research & Practice

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Sara Gilbert

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    About the Author

    Sara Gilbert is a chartered clinical psychologist with over 30 years of experience. Her interest in problems with over- and under-eating developed out of a research project into the psychology of obesity in a hospital clinic in 1978–81. For the past 20 years she has specialized in the treatment of eating disorders, with people whose difficulties are expressed through eating too little or through problems with controlling what they eat. She recently retired from her NHS post as joint service lead of the community eating disorders service in Bedfordshire (South Essex Partnership Trust) and now works in private practice in London.

    Sara's approach to therapy is broadly cognitive behavioural but she sees herself as an integrative therapist in that she draws on a combination of several other approaches to inform her work. She believes that the role of the therapist is to work with clients to build a joint understanding of their current difficulties in order to develop a treatment plan which fits best with evidenced based ideas and the client's own objectives and aspirations. Her aim in therapy is to help clients to learn ways to make changes for themselves, so that they can work towards becoming their own therapist or coach.

    Sara's other publications include Pathology of Eating: Psychology and Treatment (Routledge, 1986 and 2014), the first systematic and comprehensive coverage of the psychological aspects of eating disorders and their treatment; and Tomorrow I'll Be Slim: The Psychology of Dieting (Routledge, 1989 and 2014).

    Preface

    I first became interested in exploring the nature of eating disorders when working in an obesity clinic in the late 1970s. At that time, the only eating disorder truly recognized was anorexia nervosa. People who were overweight or of normal weight, and who could not control their eating, fell sadly between two stools. Either they were forced to fit into medically oriented dietetic or nutrition clinics, where their apparent lack of motivation to do as they were advised was viewed askance by the people who tried to treat them; or they were assumed to be depressed, or even to be suffering with a personality disorder, and offered temporary shelter under a psychiatric umbrella, which was just as inappropriate. It became increasingly clear that what these people needed was something different, something which addressed the specific problems of their disorders, and which did not force them to pursue an answer which relied on their problems having an entirely physical origin or to be labelled as suffering from some form of insanity.

    While the origin of eating disorders remained poorly understood, it made increasing sense to treat them with a cognitive behavioural approach, encompassing as it does a collaborative therapeutic style, the teaching of self-control to clients, and a way of exploring the meaning of their difficulties together with clients. Since the publication of the first edition of this book 12 years ago, cognitive behaviour therapy has become more firmly established as a treatment of choice for the eating disorders with a strong evidence base, and I have updated the literature and references cited in the book to take account of new developments in theory and practice. Some of the more recent developments in cognitive therapy that may also lend themselves to working with people with eating disorders, and in particular in relation to helping people to tolerate emotional distress, include methods often referred to as ‘third-wave’ cognitive therapies: with ideas from the work of Marcia Linehan (1993a, b) in relation to dialectical behaviour therapy in the treatment of borderline personality disorder; Hayes and others (1999) in relation to acceptance and commitment therapy; and Segal, Williams and Teasdale (2013) in the development of mindfulness-based cognitive therapy.

    In this book, I have attempted to describe how to offer therapy to people with eating disorders from a cognitive behavioural point of view. In doing so, I must acknowledge that the origin of many of these ideas is influenced by a combination of many sources, including my reading of the works of Aaron Beck and his colleagues, of Christine Padesky in relation to cognitive therapy for depression and other disorders, and of Hilde Bruch, Christopher Fairburn, David Garner, Paul Garfinkel and Kelly Bemis Vitousek, among others, in relation to eating disorders.

    In updating a book of this nature and scope, it has not been possible to give detailed coverage of all aspects of eating disorders, but I have referenced the work with a large number of relevant contemporary sources so that the reader can pursue individual topic areas in further detail. In describing a broadly cognitive behavioural approach, I have assumed a basic knowledge of cognitive behavioural and generic therapy techniques. (For more details of how to use cognitive behavioural techniques to elicit and answer, for example, negative automatic thoughts and to arrive at underlying assumptions, I would refer readers to Judith Beck's [1995] excellent manual.)

    There are now several excellent self-help books available that outline cognitive behavioural protocols, some of them evidence based, and similar to those which have been subject to much research into the treatment of bulimia nervosa in particular. However, while protocols are helpful as a starting point, in this book I have taken an integrative stance and drawn on ideas from the cognitive and behavioural fields, many of them researched in practice, which can be tailored in varying combinations to the treatment of individual clients and their idiosyncratic problems. For example, I have drawn on ideas about enhancing motivation for treatment, schemas about the self and interpersonal relationships, and eating disorder as a means of coping with negative affect. I have avoided giving exact prescriptions of when and where to introduce specific techniques as it will be up to individual therapists to decide, together with their clients, at what point in therapy each approach might be most useful.

    In the following chapters, I have on many occasions used the pronoun ‘she’ to refer to clients, rather than the more clumsy ‘she/he’ or ‘they’, and have made this choice merely because most sufferers are female. However, the ideas may apply equally to male sufferers, who have much in common with female sufferers. The case histories I have described are not those of real people. Rather, they are composites derived from clients I have met, and with the details of their stories and their names changed so as to preserve the confidentiality of the real people on whom they are loosely based.

    Finally, this book could not have been published without the work and encouragement of several people. Windy Dryden, series editor, suggested that I write the book several years ago. His constructive criticism of drafts of the first chapters helped me to set the style for the book as a whole. Despite the many obstacles to my meeting deadlines, Windy was unfailing in his patience and in his belief that I would complete it as promised. My thanks go to Kate Williams, dietician, for her comments on an earlier draft of Chapter 7 in this edition. I am grateful to colleagues past and present for the many discussions we have had over the years which have helped to shape my ideas about the nature and treatment of eating disorders, in particular: Jay Chatterton, Jacqui Dabney, Gary Kupshik and Faith Whittle. I should also like to acknowledge the hard work of the many editorial staff of Sage who have been involved in this book in all its reincarnations: Melissa Dunlop, Justin Dyer for his relentless and painstaking editing of the text, Rachel Burrows, Kate Scott, Susannah Trefgarne, Laura Walmsley, Louise Wise, and Kate Wharton, and in particular Susan Worsey for her support and encouragement over long periods when personal circumstances made it impossible for me to write.

    Sara Gilbert2013

    Acknowledgements

    The author and publisher wish to thank the following publishers for kind permission to reprint material: the Guilford Press for permission to adapt a table from W.R. Miller and S. Rollnick, Motivational Interviewing: Preparing People to Change Addictive Behavior, 1991 (Table 6.1); Springer Science+Business Media B.V. and the authors for permission to adapt a table from D.M. Garner and K. Bemis, ‘A cognitive-behavioral approach to anorexia nervosa’, Cognitive Therapy and Research, 6, 1982 (Table 9.1); the Nutrition and Dietetic Department of North West London Hospitals NHS Trust, 2013 for permission to reproduce their revised version of the leaflet ‘Eat for Health’ in Appendix 3; Quartet Books for permission to adapt material from Anne Dickson, A Woman in Your Own Right: Assertiveness and You (1982), pp. 29–36 (Appendix 6).

  • Some Useful Web Pages

    www.edauk.com – the website of the Eating Disorders Association in the UK, a voluntary body which aims to offer information and advice to sufferers.

    www.nationaleatingdisorders.org – website of the National Eating Disorders Association, a ‘non-profit organization in the United States working to eliminate eating disorders’ which has a clinical and advisory council comprising many of the published academic names in eating disorders in the US. The website includes an alphabetical list of information for sufferers and families.

    www.nedic.ca – National Eating Disorder Information Centre, a Toronto-based, non-profit organization which provides information and resources on eating disorders and weight preoccupation.

    www.anred.com – Anorexia Nervosa and Related Eating Disorders, Inc. (ANRED), a non-profit organization in the US providing information about eating disorders, including about 50 documents covering definition, statistics, warning signs, causes, treatment and self-help suggestions.

    www.feast-ed.org – Families Empowered and Supporting Treatment of Eating Disorders, ‘an international organization of and for parents and caregivers to help loved ones recover from eating disorders by providing information and mutual support, promoting evidence-based treatment, and advocating for research and education to reduce the suffering associated with eating disorders.’

    www.nice.org.uk – follow the links to eating disorders to see NICE guidelines (for the UK).

    www.psychiatryonline.org – publishes practice guidelines of the American Psychiatry Association and ‘guideline watches’ or articles highlighting significant developments relevant to specific guidelines.

    www.rcpsych.ac.uk – Royal College of Psychiatrists website (UK). Follow the links to see the MARSIPAN (Management of Really Sick Patients with Anorexia Nervosa) guidelines. For children, the report is numbered CR168, January 2012; for adults, the report is CR162, October 2010.

    Eating Problems: Resources for Clients

    Many people with an eating disorder are helped by reading. There follows a comprehensive list of books which offer self-help advice or information about problems related to eating disorder.

    Information about Eating Disorders and Self-Help

    Carrie Arnold (2013) Decoding Anorexia: How Breakthroughs in Science Offer Hope for Eating Disorders. London: Routledge.

    Ellen Astrachan-Fletcher and Michael Maslar (2009) The Dialectical Behaviour Therapy Skills Workbook for Bulimia: Using DBT to Break the Cycle and Regain Control of Your Life. Oakland, CA: New Harbinger.

    Kim Chernin (1994) The Hungry Self: Women, Eating and Identity. New York: Harper Perennial.

    Jan Chozen Bays (2009) Mindful Eating: A Guide to Rediscovering a Healthy and Joyful Relationship with Food. Boston and London: Shambhala.

    Myra Cooper, Gillian Todd and Adrian Wells (2000) Bulimia Nervosa: A Cognitive Therapy Programme for Clients. London: Jessica Kingsley.

    Christopher Fairburn (1995) Overcoming Binge Eating. New York: Guilford Press.

    Christopher Freeman (2009) Overcoming Anorexia Nervosa. London: Robinson.

    Ken Goss (2011) The Compassionate Mind Approach to Beating Overeating using Compassion Focused Therapy. London: Robinson.

    Michael Heffner and Georg Eiffert (2004)The Anorexia Workbook: How to Accept Yourself, Heal your Suffering, and Reclaim your Life. Oakland, CA: New Harbinger.

    John F. Morgan (2008) The Invisible Man: A Self-help Guide for Men with Eating Disorders and Bigorexia. London: Routledge.

    Ulrike Schmidt and Janet Treasure (1993) Getting Better Bit(e) by Bit(e). Hove: Psychology Press.

    Jennifer Taitz (2012) End Emotional Eating: Using Dialectical Behavior Therapy Skills to Cope with Difficult Emotions and Develop a Healthy Relationship with Food. Oakland, CA: New Harbinger Publications.

    Janet Treasure and June Alexander (2013) Anorexia Nervosa: A Recovery Guide for Sufferers, Families and Friends. London: Routledge.

    Glenn Waller, Victoria Mountford, Rachel Lawson, Emma Gray, Helen Cordery and Hendrik Hinrichsen (2010) Beating your Eating Disorder: A Cognitive-Behavioural Self-help Guide for Adult Sufferers and their Carers. Cambridge: Cambridge University Press.

    Help for Families

    Bryan Lask and Rachel Bryant-Waugh (2013) Eating Disorders: A Parents ’ Guide. 2nd edn. London: Brunner Routledge.

    James Lock and Daniel Le Grange (2005) Help your Teenager Beat an Eating Disorder. New York: Guilford Press.

    Roberta Trattner Sherman and Ron A. Thompson (1997) Bulimia: A Guide for Family and Friends. San Francisco: Jossey-Bass.

    Michele Siegel, Judith Brisman and Margot Weinshel (1997) Surviving an Eating Disorder: Strategies for Family and Friends. New York: Harper Perennial.

    Self-Help for Emotional Difficulties

    Lorraine Bell (2003) Managing Intense Emotions and Overcoming Self-destructive Habits: A Self-help Manual. London: Brunner Routledge.

    David Burns (1999) Feeling Good: The New Mood Therapy. Rev. edn. New York: Avon Books.

    Paul Gilbert (1997) Overcoming Depression: A Self-help Guide Using Cognitive Behavioural Techniques. London: Robinson.

    Paul Gilbert (2010) The Compassionate Mind: How to Use Compassion to Develop Happiness, Self-acceptance and Well-being. London: Constable.

    Kim L. Gratz and Alexander L. Chapman (2009) Freedom from Self-harm: Overcoming Self-injury with Skills from DBT and Other Treatments. Oakland, CA: New Harbinger.

    Dennis Greenberger and Christine Padesky (1995) Mind over Mood: A Cognitive Therapy Treatment Manual for Clients. New York: Guilford Press.

    Helen Kennerly (1997) Overcoming Anxiety: A Self-help Guide Using Cognitive Behavioural Techniques. London: Constable and Robinson.

    Matthew McKay, Jeffrey Wood and Jeffrey Brantley (2007) The Dialectical Behavior Therapy Skills Workbook. Oakland, CA: New Harbinger.

    Ulrike Schmidt and Kate Davidson (2004) Life after Self-harm: A Guide to the Future. London: Brunner Routledge.

    Elizabeth Wilde McCormick (2012) Change for the Better: Self-help Through Practical Psychotherapy. 4th edn. London: Sage.

    Mark Williams and Danny Penman (2011) Mindfulness: A Practical Guide to Finding Peace in a Frantic World. London: Piatkus.

    Body Image

    Lorraine Bell and Jenny Rushforth (2008) Overcoming Body Image Disturbance: A Programme for People with Eating Disorders. London: Routledge.

    Thomas Cash (2008)The Body Image Workbook: An 8-Step Program for Learning to Like your Looks. 2nd edn. Oakland, CA: New Harbinger.

    Self-Esteem and Relationships

    David Burns (1999) Ten Days to Self-esteem. New York: William Morrow.

    Gillian Butler (2001) Overcoming Anxiety and Shyness: A Self-help Guide Using Cognitive Behavioural Techniques. New York: New York University Press.

    Anne Dickson (1982)A Woman in Your Own Right: Assertiveness and You. London: Quartet Books.

    Melanie Fennell (1999) Overcoming Low Self-esteem: Self-help Guide Using Cognitive Behavioural Techniques. London: Constable and Robinson.

    Childhood Abuse

    Carolyn Ainscough and Kay Toon (2000) Breaking Free: Help for Survivors of Child Sexual Abuse. London: Sheldon Press.

    Carolyn Ainscough and Kay Toon (2000) Surviving Child Sexual Abuse: Practical Help for Adults Who Were Sexually Abused as Children. London: Sheldon Press.

    Susan Forward (1989) Toxic Parents: Overcoming the Legacy of Parental Abuse. London: Bantam Press.

    Eliana Gil (1983) Outgrowing the Pain. New York: Bantam Dell.

    Helen Kennerly (2000) Overcoming Childhood Trauma: A Self-help Guide Using Cognitive Behavioural Techniques. New York: New York University Press.

    Penny Parks (1990) Rescuing the Inner Child: Therapy for Adults Sexually Abused as Children. London: Souvenir.

    Guidelines for Normal Healthy Eating

    Eating a variety of foods at regular intervals is important for good health. This will provide the energy and range of nutrients you need. It is possible to maintain a normal body weight by choosing from the different food groups, as explained with the EatWell Plate Model.

    Choose foods from each of the following groups every day:

    • bread, and cereals
    • fish, meat, eggs, pulses and nuts
    • milk, cheese and yogurt
    • fruit and vegetables
    • fats and oils
    Bread, Rice, Potatoes, Pasta

    (Include wholegrain varieties of rice, pasta and breakfast cereals). Include starchy foods at each meal. Aim to eat a minimum of 6 portions each day. NB: tbs = rounded serving spoon

    1 portion equals1 slice of bread from large loaf
    1 small roll
    ½ small pitta bread
    1 small chapatti
    4 tbs (9 g/3 oz) boiled rice or pasta
    2 egg-size potatoes
    30 g/1 oz breakfast cereal
    1 Weetabix or Shredded Wheat
    3 crispbread (e.g., Ryvita)
    1 digestive biscuit or 2 plain biscuits
    Meat, Fish, Eggs, Beans

    Include at least 2 portions from this list every day

    1 portion equals2–3 slices (90 g/3oz) lean cooked meat
    120 g/4 oz cooked fish
    30 g/1 oz hard cheese
    40 g/1½ oz medium fat cheese, e.g., Edam, Brie, Camembert
    3 tbs (120 g/4 oz) cottage cheese or fromage frais
    1–2 eggs
    3 tbs (120 g/4 oz) cooked pulses (peas, beans and lentils)
    4 tbs (140 g/5 oz) baked beans
    60 g/2 oz nuts (peanuts, almonds, brazils)

    Combining pulses (peas, beans and lentils) with cereals, such as bread, rice or pasta (e.g., beans on toast or bean casserole and rice), provides a good variety of proteins.

    Milk and Dairy

    Include 1 pint (600 ml) of milk per day – some can be swapped for yogurt, cheese or alternatives.

    1 cup (1/3 pint/200 ml)= 125 g (1 pot) natural or fruit yogurt
    = 30 g (1 oz) or ‘matchbox size’ of cheese
    Non-dairy sources= 200 ml soya/rice/oat milk with added calcium
    = 125 g (1 pot) of soya yoghurt with added calcium
    = ½ can of sardines (with bones)
    = 1 can of pilchards (with bones)
    Fruit and Vegetables
    Fruit – at Least 3 Helpings a Day

    Include citrus fruit (e.g., oranges, grapefruit and their juices), as these are a good source of vitamin C. Other types of fresh, cooked, dried and tinned fruit in natural juice are also useful.

    Vegetables – at Least 2 Helpings a Day

    Include dark green varieties (e.g., cabbage or broccoli), as well as salad vegetables (e.g., tomatoes, carrots, celery and sweet peppers).

    Frozen vegetables are just as nutritious as fresh ones. Do not overcook vegetables as this reduces their vitamin content. Steam or cook in a small amount of boiling water for the shortest possible time.

    Fats and Oils

    Some fat is needed for good health. At least 3 teaspoons of butter, margarine or oil should be used daily.

    Table A.1 Suitable Snacks
    Fresh fruitSandwichesToast
    Plain biscuitsFruit loafDried fruit
    SconesYogurtNuts
    Suitable Snacks
    Fluids

    It is important to drink enough fluid each day: 6–8 cups of water, fruit juice, tea or milk, rather than coffee, cola or diet drinks.

    Suggested Meal Plan

    Reproduced with the kind permission of the Nutrition and Dietetic Department of North West London Hospitals NHS Trust, 2013.

    Table A.2 Suggested Meal Plan
    Breakfast:Fruit juice or fresh fruit
    Breakfast cereal or porridge and/or bread or toast with butter or margarine
    Tea/coffee
    Mid-morning:Drink of choice Snack, if desired
    Lunch:
    • Bread, potatoes, rice or pasta
    • Meat, fish, cheese, eggs or beans
    • Cooked vegetables or salad
    • Fruit, yogurt or dessert
    Mid-afternoon:
    • Drink of choice
    • Fruit/snack, if desired
    Evening meal:
    • Potatoes, rice, pasta or bread
    • Meat, fish, cheese, eggs or beans
    • Vegetables or salad
    • Fruit, yogurt or dessert
    Bedtime:
    • Milky drink
    • Snack, if desired

    Controlling what you Eat

    Altering your Surroundings to Make Food Less Important

    If you are someone who eats when you see food, when you see other people eating, or even because you are thinking about food, some of the following suggestions might help you to plan for change:

    1. Eat Only in One Place

    If you are someone who eats in several rooms in the house, or wanders around idly munching, it may be helpful to you to decide to eat in one place only, preferably sitting down, at a table.

    2. Do Nothing Else While Eating

    Perhaps you eat while watching television or reading a book. The more able you are to make eating a ‘pure’ experience, the less inclined you will be to eat just out of habit, because that is usually what you do when the TV is on, while you are reading, or because you happen to see food lying around. Some people have suggested that you are very rigid about this, eating always in the same place. This means, for example, that if you are in the lounge watching the TV and you fancy a piece of cheese you have to go to the kitchen, eat, and return to the TV when you have finished. If you want another piece, you have to go back, cut another piece, eat it there and return to the TV again; the idea is not to bring the whole cheese into the TV room with you. Eating in this way can help people to be more aware of what they are eating and helps to avoid ‘mindless’ eating; for example, finishing a plate of biscuits without noticing because you are busy doing something else at the same time.

    3. Eat Only with a Knife and Fork

    Another technique is to eat everything with a knife and fork on a plate: this goes for anything – apples, even chocolate. The reasoning behind this is that you therefore restrict the surroundings in which you eat, which may as a consequence help you to eat less, particularly of snack food.

    4. Make Eating Extra Snacks and Helpings More Difficult

    Do you find it hard to resist eating when you see food? For example, you may eat because other people are eating, or polish off leftovers (‘It's not worth leaving that little bit’).

    • Try keeping snack foods in opaque containers, out of impulse range in a cupboard.
    • Get the family to prepare and fetch their own snacks.
    • Have low-calorie snacks available to eat while other people are nibbling.
    • Don't leave the serving dishes on the table. Make it more difficult to go for ‘seconds’.
    • Practise throwing away leftover food. This is something that many of us find very dif ficult, but there is no point in leaving it sitting in the fridge to tempt you if you are going to spend half an hour soul-searching and end up eating it anyway. It is quite reasonable to exercise control by making leftover food unavailable in the waste-bin. Perhaps, at a later stage in your programme, you will be better able to resist food that is on show, but if you cannot at first, there is no point in struggling. Throwing away leftover food is no more wasteful than eating it yourself if you have no need for it, in which case, it can do a great deal of harm to you and your self-esteem and no good whatsoever to the starving masses.
    5. Shop with a List

    Keep problem, high-fat, high-sugar food out of the house, if possible, or try to avoid situations where you might buy it out of habit. One example of this is to shop with a list, so as to avoid buying calorific treats or special offers at the supermarket checkout, when you are at your most vulnerable after the effort of making several choices from the tempting displays. Try not to shop for food when you are hungry. You might make it a target not to buy biscuits or snack foods ‘for the children’ or ‘for when my friends come’. (Will there really be any left for the children? The visitors might get some, but will you have eaten twice as much before they arrive?) If you cannot walk past the patisserie or the confectioner's without going in, try walking round the shops or home from work in a different direction.

    6. Avoid Extreme Hunger or Boredom

    Being hungry or bored or tired can only make you more vulnerable to ‘impulse’ eating, if the food is there.

    7. Ensure that you Get Enough Sleep

    There is increasing scientific evidence of a link between having less sleep and weight gain or obesity. Even though you may use more energy when you are awake for longer, people who get less sleep eat more on average than people who get more sleep. Getting more sleep on its own will not help you to lose weight, but being less tired and more energetic can mean that you will feel less like ‘grazing’ and will help you keep your reserves of ‘willpower’ topped up so that you are less likely to want to overeat.

    Thoughts about Food

    If you are trying to change an eating habit, you are even more likely than usual to find yourself thinking about food. Try to decide whether you really are hungry or not. This is not easy, but you may perhaps have just eaten; you may be particularly vulnerable to thinking about food when bored or miserable or perhaps just seeing and thinking about food makes you want it. If you have decided that you have no reason for physical hunger, you might try distracting yourself from the thought of food by doing something else, perhaps taking some exercise. It helps to have a list prepared of activities that you can do where eating at the same time would be difficult: for example, working on a craft activity, gardening, typing emails, sewing, swimming. If all else fails, try substituting a craved food such as chocolate, with something else: eating something may give you the energy you need to replenish your store of willpower.

    Is the Way you Eat a Problem?

    If you eat very fast, sometimes perhaps without realizing how much you have eaten, it can help to take some practical steps to alter the way you eat.

    Try eating more slowly. You could practise chewing your food more slowly, keeping the food in your mouth for longer intervals before swallowing. In order to slow the pace of eating even further, you might try pausing between mouthfuls, putting your knife and fork down while you swallow, and picking them up again when your mouth is empty. You might practise making the intervals between mouthfuls longer by counting to a higher number each time.

    Practise ‘mindful’ eating: concentrating on the taste, the textures and sensation of the food in your mouth (see text box).

    Tackle Problems Gradually

    Changing old habits takes time. Before you can say that a habit has changed, you will have had several false starts; you will simply have forgotten your intentions on some occasions; you will have tried to do things differently only to be foiled by countless unexpected events beyond your control, or by you yourself. It is better to succeed with changing one small habit than to fail at an attempt to change everything at once.

    Keep a Record of your Progress, Every Day if Possible

    If putting pen to paper seems too much like hard work, bear in mind that many of us, when we are trying to change old habits, remember only our failures and forget the times when things went well. Writing things down will underline your successes and help you to work out what to do when things went wrong.

    Giving up Vomiting as a Way to Control your Weight or Deal with Stress

    What is Wrong with Vomiting to Control your Weight?
    You cannot Completely Stop Food from being Absorbed

    Vomiting is a very ineffective way of emptying the stomach. It removes only some of the food eaten, together with a great deal of water. Some of the food will still be absorbed, and although your stomach may feel emptier, you may soon feel hungry again.

    Vomiting Strengthens the Vicious Cycle of an Eating Disorder

    The habit of vomiting locks people into their cycle of eating disorder. There are three reasons for this:

    • Knowing that you can vomit after meals gives you the false reassurance that you can undo the effects of eating. If you binge, you will be less inclined to stop. If you are underweight and need to gain weight, vomiting when you eat can remove the anxiety about gaining weight but prevents you from learning to eat without fear.
    • If you vomit, you empty your stomach and will soon feel hungry again. You may crave food and, if you already have a binge habit, this will lead you into further bingeing.
    • Once vomiting after food has become a habit, people who use it begin to believe that if they do not vomit they will gain weight. They learn to link the feeling of emptiness after vomiting with reassurance and relief, and they grow to feel more and more uncomfortable about the opposite feeling, that of having a full stomach. They become increasingly dependent on being able to vomit. They may even plan their routine around making sure that they will have the opportunity to do so.

    Knowing that they intend to vomit, many binge eaters decide that in order to make vomiting worthwhile they may as well eat a large amount of food. Some feel that they can vomit only after they have eaten a large amount of food and have a full stomach.

    So, the decision to vomit sometimes creates a feeling of inevitability and some sufferers will go ahead and fill up on a range of foods that they would normally not allow themselves to eat. This serves only to keep the binge–vomit cycle going and can lead ultimately to increased weight gain.

    The Dangers of Vomiting

    Besides its ineffectiveness as a means of weight control, vomiting is physically dangerous. Repeated vomiting upsets the body's fluid balance and depletes the body of important minerals, such as potassium and sodium. Low potassium can cause muscular cramps and weakness, kidney damage, heart arrhythmias and even, in severe cases, sudden cardiac arrest. In addition, vomit contains hydrochloric acid, which is produced by the stomach to digest food. The presence of this acid in the mouth gradually damages the teeth by eroding away tooth enamel. This enamel cannot be replaced, although if you stop vomiting, the teeth will not be damaged any further.

    Vomiting also causes some of the saliva-producing glands around the face to swell. One of these glands is the parotid gland. When this gland is swollen, it gives the face a rounder appearance, and many people see themselves as having a fat face, which only further convinces them that they are fat and need to lose weight. The belief that they are fat only serves to keep them stuck in their pattern of eating disorder.

    Some Ways to Control Vomiting

    The habit of vomiting to control weight can be extremely powerful, and the first task of the person with an eating disorder is to decide that they really want to stop. For some people who binge eat, the vomiting stops or becomes less frequent automatically during treatment as the number of binges becomes less. In fact, in some treatment programmes aimed at treating bulimia nervosa, no specific advice is given with regard to vomiting as in many cases once people have cut down their bingeing the vomiting disappears of its own accord.

    However, other people need to take more definite steps to cut down the vomiting. What follows are some ideas that people have found useful.

    • Keeping a record. First, you should keep a record, together with any bingeing, of instances of vomiting: the date and time; the place; the situation (who with, what were you doing at the time or what had you been doing just before?); how you were feeling; what you were thinking about just beforehand; what you had eaten/drunk just before vomiting.
    • Delaying tactics. The urge to vomit is usually strongest soon after a meal. One very important strategy is to concentrate on lengthening the time between eating and vomiting. So, if you tend to vomit immediately after eating, try giving yourself increasing periods of time between eating and vomiting. Ideally, you should try to create a time delay of at least an hour after eating. You can tell yourself: ‘I can vomit, but I have to wait for an hour.’ If this is impossible, you can start with five minutes, moving quickly to ten minutes, then 15 minutes, and so on. In the meantime, your task is to relax as far as possible and give yourself time to become used to the feeling of the food inside you.
    • Distraction. The aim is to break the association of vomiting with eating or with a feeling of fullness, and in order to do this you need to become used to the physical feeling of being full and give yourself time to experience the emotions that go with it. If at first, this makes you feel very anxious, one strategy is to distract yourself from the feelings. You can take yourself out of the situation altogether. Go to a place where it is impossible to be sick, find a job or activity to do, such as talking to a friend, going for a walk, sending an email, even clearing out a cupboard or drawer. If you cannot remove yourself physically, an alternative strategy is to use the time to work on some complicated idea in your head – working on a mathematical puzzle, visualizing a place you have been to, concentrating on imagining every detail.
    • Relaxation. Another way of coping with this time is to find a way to relax and allow the difficult feelings to wash over you. You might try using a physical relaxation technique, either lying down or sitting somewhere comfortably. Ask your therapist for specific advice about this.
    • Going with the feelings. Another, perhaps more effective, strategy in the long run is to allow yourself to experience the often difficult feelings you have immediately before vomiting. Some people say that they do not feel anything: there is simply an urge to vomit. But if they stop and listen to what is going though their heads, many people are able to focus more clearly on the powerful, sometimes painful, ideas and feelings that can trigger their behaviour again and again. Some people are able to recognize thoughts about being fat and the fear of going out of control if they allow themselves to eat. Try writing these down. Other people notice that the vomiting has become a way to get relief from painful feelings. These can be, for example: intense anger, with someone else or with oneself; anxiety or excitement (not necessarily always negative); feelings of self-hatred or shame, which are very common in people who have an eating disorder. You may recognize other feelings. It is important to recognize that, however scary and intense the feelings are, they are only feelings. They are not facts. Vomiting may seem to distract you or get them out of your system temporarily, but talking about them and looking for ways to deal with them, together with your therapist, can help to change them permanently.

    Learning to be Assertive about what you Eat: A Bill of Rights

    Sometimes the biggest problem for a person with an eating disorder can be learning to follow their own food desires. This is where it helps to be assertive. Being assertive means to ask for what you want in a straightforward way, without being either aggressive or manipulative.

    Some of us (and not only dieters) have a great deal of difficulty in telling other people what we want from them or simply in saying ‘No’. We all have basic rights with regard to ourselves and other people. Below are some examples of these rights. You may be able to add others to the list.

    I have the Right to State my Own Food Needs

    So often, other people tell us when we are supposed to be hungry, or when we are supposed to be full up: ‘You haven't eaten all day, have another helping.’ ‘You've been eating all afternoon, haven't you had enough?’

    I have the Right to Decide how much I Want to Eat and when, Regardless of any Social or Work Situation I May Find Myself in

    ‘Come on, don't be a spoil sport. We are all here to enjoy ourselves. Have a cream cake/another drink.’ You do not have to eat to make other people feel comfortable.

    I have the Right to Express how I Feel

    If you feel hungry, it is OK to say so. If you are not hungry, it is your right to say so. ‘I'm not hungry. I won't have any thank you.’

    I have the Right to Say ‘Yes’ or ‘No’ for Myself

    Once people know that you have a problem around food, they can develop an annoying habit of telling you what you should be eating. For example: ‘It's not good for you to cut out sweet things altogether. You'd better have some of these to give you some energy.’ Or ‘You won't want any cake, will you?’ It is up to you to choose what is appropriate for you to eat, and if you want to eat something that is not allowed on your diet, you have the right to choose to eat it.

    I have the Right to Make Mistakes

    It is only human to make a mistake. You do not have to feel guilty every time you forget your plan and eat more or less than you intended to.

    I have the Right to Ask for what I Want

    Sometimes this may conflict with what other people want or expect. If you are with others, it is often easiest to go along with what they want: but, at home, you have the right to say what you want on the menu; in a restaurant, you do not have to eat the same as everyone else; and, in someone else's house, you have the right to state a preference: ‘No pudding for me thank you, but I'd love a peach from the fruit bowl.’

    I have the Right to Decline Responsibility for Satisfying Other People's Needs

    It is often considered a slight to another person not to eat the food that he or she has provided. However, it is not necessary to put the feelings of another person before one's own good health. You can show your appreciation for another person in words, without necessarily eating every scrap of food he or she has provided: ‘It looks lovely, but I won't/can't eat another thing thank you.'

    I have the Right to Deal with Others without being Dependent on them for Approval

    We are often afraid to ask for what we want or to stand up for our rights for fear of another person's disapproval. This extends sometimes even beyond our close family and friends to our dealings with people we do not know. We hesitate to leave food on our plate in the restaurant or to send back the chips that we did not order for fear of upsetting the waiter. The more often you practise assertion skills, the easier it gets to ask for what you want without fear of the disapproval of other people, and the more you gain in confidence in yourself.

    Adapted, with the kind permission of the publisher, from Anne Dickson (1982)A Woman in Your Own Right: Assertiveness and You. London: Quartet Books, pp. 29–36.

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