“The core.... problem here is the over-evaluation of food, shape and weight as threats. This manifests as beliefs such as ‘If I eat normally my weight will rocket out of control and I will never be able to stop it".”
The eating disorder mindset is very much more complex of course. There are many other beliefs which affect our behaviour with food, such as beliefs about good foods and bad foods, binge foods and safe foods and making a tragedy out of eating an extra piece of toast. Even a fat person who thinks “I will die if I do not get my treats” suffers from a distorted mindset.
It might be useful to create a whole library out of all the beliefs we encounter in someone with an eating disorder. Some of these beliefs are really just the reflection of the “real issue” underneath, which is feeling out of control. Poor self regard, feelings of ineffectiveness, mistrust of others and worthlessness are the real source of the “cognitive problem.”
We must be careful not to dismiss some of these ideas. People do have differences in their “normal appetites” and there is a place for primary disturbances of appetite in how we think about eating disorders. This means that many people have to live in a continual state of mild restraint in order to control their weight. Is that “normal eating?” I may eat “normally” and I hardly think about food and weight. But I am pretty convinced that if I were to eat exactly what I wanted, I would be heavier than I am and possibly mildly overweight, which carries health risks. Saying “no” to an extra piece of cake is par for the course and part of the way we must respond to the world we live in if we are to avoid gaining a great deal of weight over time.
So, all psychotherapists must reflect on what normal eating really is before leaping to change mindsets, and that is a whole new essay. We need to discuss the idea of normal eating with our clients before we help them to amend their ideas. Many people with anorexia do not value “normal eating” because of other values associated with normal eating such as “people who eat what they like are greedy and disgusting”.
Or, conversely, some people with weight problems may not wish to eat normally if they believe that “people who eat what they like are fun loving and sociable”.
Professor Waller (CBT Today Dec 2010) states that if what we are doing does not explicitly target these beliefs it is not “CBT for eating disorders”.
The eating disorder practitioner needs to know more than CBT if treatment is to work. CBT while crucial does not work on its own for all people, especially for anorexia. It seems to me that framing up a therapy as belonging to a specific treatment model is safe for therapists, so when we have a new tool such as “mindfulness” we call it “Mindfulness based CBT” or, if we add emotional tools to our treatment we can call it “Cognitive –Emotional Behaviour Therapy”.
It really scares me however, to think of how many therapists don’t know or understand the principles of mindset change or how to do it. Empathy, giving our clients unconditional positive regard and even working on self esteem or early trauma isn’t enough. We owe it to sufferers to understand every aspect of how they think, how they process information (such as through the filters of all-or-nothing thinking) and how this affects their behaviour, before we should consider working with them.