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Cognitive-behavioral treatment for bulimia: stage two and stage three COGNITIVE-BEHAVIORAL TREATMENT FOR BULIMIA: STAGE TWO AND STAGE THREE
Stage two
During the second phase, we continue to work on developing regular eating habits. We also begin to change the makeup of her diet.
As we have seen, people with eating disorders often adopt rigid rules about what can and can't be eaten. They create a list of "forbidden foods"-fattening or sweet foods they want but won't allow themselves to have. Avoiding these foods makes them feel in control. However, these are often the very foods they run to when they lose control and binge.
It's a quirk of human nature: Whatever is forbidden becomes the thing we most desire. When a bulimic decides certain foods are "off limits," she creates an overwhelming temptation. In Stage Two, we work to reduce her feeling that she is completely helpless in the presence of forbidden foods. The goal is to take the power away from food and return it to the patient.
One method is to rank these foods in order of "danger level" and then gradually reintroduce them into the diet, starting with the least "dangerous" food. When she learns she can eat a few French fries, for example, and not feel driven to binge, she starts to feel in control. Success breeds success. Regaining a little bit of control reduces fear and gives her encouragement to keep trying. She may need a lot of coaching from her therapist and from others in her family to reach this point.
The best way to handle a phobia is to gradually increase exposure to the thing you fear. When the patient learns how to manage forbidden foods, she conquers some of her fears. Sometimes, for example, a patient tells me she will only eat something if she knows its calorie content. As an exercise, then, we work on eating foods whose calories are unknown. Or she may dread eating in restaurants or at parties. We find ways to expose her to those situations and build up her tolerance. Doing so takes her out of the "danger zone."
One method to help with purging is technically known as exposure plus response prevention. We expose the patient to the problem-feeling full after eating-and prevent her usual response to it-vomiting. If the patient is in the hospital, we ask her to sit with a staff member for an hour or so after a meal. Eventually she gets used to the feeling of having food in her stomach. She learns that she needn't respond to the feeling by giving in to her urge to purge. This strategy works especially well when the patient vomits often, or when eating anything at all triggers purging. If needed, we can use the method with outpatients as well.
During the second stage, the patient does better if she reduces her "magical thinking" about food. She also needs to learn new ways of thinking about, and solving, her problems. As I'll explain shortly, cognitive therapy helps her achieve these goals.
In many cases, at the end of the second stage the patient has stopped bingeing completely, or binges only once in a while. Her attitudes about weight, body shape, and herself are much healthier.
Stage Three
During the third phase, we continue to build on successes during the previous stages - continuing regular eating and relaxing the patient's need to control her diet. But now we shift our focus and prepare the patient to leave therapy and strike out on her own.
Many patients notice that their normal feelings of hunger and fullness have returned. This in itself makes it easier to control eating. We still work with the food diary, which will indicate whether there's a problem that we still need to work on.
In fact, slipping back gives us a chance to address a key issue: the risk of relapse. Patients are always in danger of slipping back into old habits. Perfectionism is hard to shake; many patients believe that once they regain control, all will be well forever. Not so. Better to face the reality that relapse is possible, especially during times of stress.
The message is that a little slip does not mean total, crushing defeat. Instead, I urge the patient to remember how far she has come, and that she has learned a lot about how to deal with her illness. Through her diary, she knows how to look at her situation and discover what may have triggered her binge. Eventually she will learn how to avoid these triggers.
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