Therapy for Eating Disorders: Theory, Research & Practice

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.

[Page 199]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.

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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.

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.

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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.

[Page 200]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.

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.

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.

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

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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.

(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[Page 202]

Include at least 2 portions from this list every day

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.

Include 1 pint (600 ml) of milk per day – some can be swapped for yogurt, cheese or alternatives.[Page 203]

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

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

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:

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.

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.

[Page 208]Practise ‘mindful’ eating: concentrating on the taste, the textures and sensation of the food in your mouth (see text box).

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.

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.

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.

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.

• 1.
  [Page 212]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.
• 2.
  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.
• 3.
  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.
• 4.
  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.
• 5.
  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.

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?’

‘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.[Page 214]

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.’

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.

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.

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.’

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.'[Page 215]

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.