Authors: Kathryn Hansen
CBT addresses thoughts that cause all types of negative feelings, but most commonly those that lead to perfectionism, poor self-image, depression, and anxiety. It is believed that once those negative feelings are relieved, the destructive eating behaviors that supposedly stem from them should lessen or go away. Again, the problem with this approach is that such harmful thoughts do not inherently cause binge eating; urges to binge cause binge eating.
I certainly still have occasional negative thoughts about my body, like most everyone does; I certainly have occasional thoughts telling me I'm not a wonderful person; I have thoughts that sometimes make me anxious or depressed; but I never have urges to binge. Negative thoughts were never the cause of my binge eating.
The behavioral part of cognitive behavioral therapy attempts to address eating habits and binge eating directly. The first goal of this type of therapy is often to regulate eating with normal meals—which was the first goal of my own therapy in college. This was supposed to take away my hunger-related binges. However, due to the relentless nature of the survival instincts, eating normally did not turn off my urges to binge.
In CBT, meal plans are often used in conjunction with a technique called "self-monitoring." I frequently used this technique when I wrote down everything I ate, along with the feelings, thoughts, and events that surrounded eating—all in an attempt to find patterns in my binge eating and discover things that triggered binge eating episodes.
Trigger
is a fundamental term in CBT: a trigger is any thought, feeling, interaction, event, or behavior that leads to a binge. A major goal of CBT is to address triggers—those factors in the patient's environment that frequently lead to binge eating. A trigger can be anything from a feeling of loneliness, to having a fight with a boyfriend, to eating a piece of chocolate cake, to drinking alcohol, to being stressed out about an exam. Through self-monitoring, I attempted to learn my triggers for my binges so that I could eliminate them from my life or develop healthier ways to handle them. If I dealt with all of my triggers, my binge eating was supposed to subside, or at least become markedly less.
However, no matter how well I managed my triggers, the urges to binge didn't go away. Through self-monitoring, I discovered, for example, that I often binged in my dorm or apartment alone at night; so I labeled "being alone at night" a trigger for binge eating. Because of this, I often tried to avoid being alone at night, and if I did have to be alone, I made detailed plans of things I could do instead of binge. Even with the best-laid plans and coping strategies, though, I still usually experienced urges to binge and I still binged.
I'll discuss triggers in more detail in Chapter 35; but for now know that without urges to binge, it would be nonsensical to say that triggers cause binge eating. Every day of my recovered life, I experience many of the things that supposedly triggered my binges in the past, but those things do not trigger binge eating today. This is not because I've somehow learned to avoid or cope with every imaginable trigger; I think it would have been impossible to discover every one and learn to cope properly with all of them. Trigger hunting was a needlessly time-consuming and complex process, and it helped me blame my behavior on many other things besides my own free choice.
Like psychodynamic therapy, CBT was an indirect way to approach my problem. But at least in CBT, I did learn two techniques to try to confront my urges to binge: substitution and distraction. Substitution involves trying to decipher the negative feelings surrounding the urges and substituting positive activities to cope with those feelings. When I got an urge, I first tried to determine what feeling had brought it on, then I attempted to deal with that feeling. So if I determined that I had an urge because I was feeling stressed, then I did some relaxation techniques—like deep breathing or taking a long bath—to try to counteract the stress. The problem was, it was naïve to think that some breathing exercises or a bubble bath was going to take away my urge to binge. After all, my body and brain were not strongly urging me to deep breathe or bathe—they were screaming for food!
No technique I ever used to deal with any of the feelings I thought caused my urges ever satisfied me, because, as I've said, there are no substitutes for binge eating. Even if I did manage to find a plausible emotional reason for my urge to binge, and even if I did manage to substitute a healthy activity, it usually didn't change the fact that I wanted to eat. Furthermore, it was rare that I actually mustered up the willpower to even follow the recommended process. My urges to binge were so uncomfortable that I usually couldn't think about anything else, much less determine what I was feeling and how I should deal with it.
I believe the "substitution" technique was actually harmful to me. When I did manage to use it, it caused me to focus all my attention on the urge to binge in an effort to decipher its symbolic meaning, and that served to give my urges even more attention and emotional significance, even more power. Attention and emotional significance given to thoughts and feelings are like winds to a fire, making those thoughts and feelings more intense. This happens on a physical level in the brain—the neural connections that produce attended thoughts and feelings become more active, more organized, and stronger.
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Focusing attention on the urges was counterproductive; what I really needed to do was stop giving the urges any attention, emotional significance, or power.
The second CBT technique for dealing directly with binge urges— distraction—involves simply engaging in any distracting activity until the urge passes, without necessarily trying to determine the negative feeling or emotions behind it. Suggestions include doing something with the hands, like cleaning or sewing, or listening to music. Patients are often told to keep lists of ten or more things they can do instead of binge when the urge arises. In CBT, just delaying binge eating for a little while is considered progress.
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I created many lists of distracting activities, but it never worked in the long run. If I could marshal enough willpower to do something else besides head to the refrigerator or nearest convenience store, then yes, distraction could delay my binges for a time. But the urge often did not go away, and even when it did, it would return as quickly as it had subsided, usually less than an hour later. It seems to me that the mind-set I needed to distract myself often compounded the problem. It's like the saying, "If you tell someone not to think about a pink elephant, the first thing they think about is a pink elephant." In the same way, trying not to think about wanting to binge made me think about wanting to binge even more. So once again, by attempting to distract myself from binge eating, I effectively gave my thoughts and feelings more attention, fortifying the faulty neural pathways that produced them.
There are many other CBT techniques, such as behavior management programs, which reward healthy behaviors, and contracts, which require patients to sign agreements to refrain from binge eating for a certain amount of time. I signed contracts with myself to make it through a certain number of days, and sometimes I did make it through that many days, but rarely more than four or five. I tried rewards for getting through a certain number of days without binge eating, like treating myself to a new CD or a movie. The problem was, the part of my brain that drove binge eating didn't want a new CD or a movie—it wanted food, lots and lots of food. During an urge to binge, it was as if my animal brain laughed at the idea of getting a new CD because, after all, what use did it have for it? "I" (my human brain) wanted the new CD, but when "it" (my animal brain) was in control, thinking about rewards for my true self did nothing to deter me.
Although CBT is considered the best and most successful form of therapy for binge eaters, it does not help everyone. Research has shown that CBT eliminates binge eating and purging in about 30 to 50 percent of patients.
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Binge eaters who do recover using CBT often have the type of recovery I described in this book's introduction as the "tamed house pet story." CBT can produce the one-day-at-a-time type of recovery, wherein the patient must perpetually stay on guard against triggers, follow a meal plan indefinitely, and constantly keep her moods and negative feelings in check to avoid relapse. Ideally, the daily struggle to remain in recovery will get much easier over time, and the eating disordered behaviors may even go away completely—but not without continuous effort.
ADDICTION TREATMENT
Addiction treatment—if it is effective—also produces the tamed house pet or one-day-at-a-time type of recovery. Addiction treatment is based on the idea that the foods a binge eater typically binges on—usually foods high in sugar and carbohydrates—are physiologically addictive; and to recover, the binge eater must abstain from those addictive foods, often indefinitely.
A patient using this approach maintains recovery one day at a time by diligently avoiding the problematic foods, because theoretically, even a small amount of sugar or carbohydrate-laden food could lead to a binge or even full-blown relapse. Of the three approaches we've discussed, addiction treatment is the least often used in treating bulimia, although it is sometimes used in conjunction with the more traditional psychodynamic and CBT approaches. Addiction treatment is more often used to manage BED and compulsive overeating.
I tried abstaining from sugar and white flour at various times during my bulimia, but this never lasted more than a day or two, and I found that complete abstinence compounded the problem. Denying myself all sugar and white flour seemed to send my animal brain into overdrive and caused me to crave those substances even more. Even those without eating disorders have cravings for any pleasurable foods that they try to eliminate from their diets, and my brain was likely more defensive than the average person's because of my past restrictive dieting. My animal brain saw any form of food restriction as a threat and therefore reacted by producing urges to binge on the very foods I tried to eliminate.
While there is some evidence to back up the theory that some foods are addicting,
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this does not mean that eating those foods causes binge eating. If sugary foods were truly addictive and truly led to a loss of control and binge eating, then I would have binged every time I ate sugary foods; but I did not. There were certainly times during my bulimia when I ate a few cookies, one piece of cake, or a few chocolates and didn't binge. The urges to binge, not the sugary foods, caused me to binge.
When urges to binge arose as I ate sugary foods, and I immediately gave in and followed those urges, it was easy to think that the sugary food caused the binge. It indeed felt like I couldn't control myself around sweets sometimes. However, there is no evidence of biologically based loss of control in bulimia, and the loss of control that binge eaters feel is only a perceived loss.
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Bulimics have control over their behavior regardless of what foods they eat. The problem is, bulimics, myself included for many years, don't know how to exercise that control. Giving up the foods that seem to cause the loss of control is, in effect, avoiding the problem. It may cut down on some urges to binge, but it only ensures that when those foods are reintroduced in the future, the urges to binge will return.
Giving up sugar and white flour can be a worthwhile lifestyle choice with many health benefits; however, it should not be a requirement for stopping binge eating. It is too difficult, unnecessary, and it can create a perception of powerlessness that can become self-fulfilling. If a binge eater believes certain foods will inevitably lead to binges, those foods
will
most likely lead to binges.
EMPOWERING THE PATTERN
The three approaches I've discussed in this chapter are not the only therapies used for treating bulimia and BED, just the most prevalent and the ones I was exposed to during my own treatment. There are other types of therapy, such as pharmacological therapy, music therapy, art therapy, hypnosis, meditation, and acupuncture; however, these less-common modes of treatment are usually used alongside one of the three main approaches. There is substantial variation within each approach and between therapists. Therapeutic techniques, nutritional protocols, and medications are different for each patient.
There is currently no simple cure for bulimia or BED. I believe this is because traditional treatment approaches do not correctly define recovery or the cause of binge eating. Because recovery is defined to include such goals as resolving one's past and developing one's identity (as in psychodynamic therapy), coping well with daily stressors and overcoming negative thinking (as in CBT), and giving up sugar and white flour (as in addiction therapy), it becomes a complex, time-consuming, and often confusing process. Also, because traditional treatment approaches assume that a multitude of other things (such as underlying issues, triggers, and problematic foods) cause binge eating, these therapies miss the real problem—the urges to binge—and sometimes even worsen that problem.
Shortly after I stopped binge eating for good, I read a book about choosing a career, and although it had nothing to do with eating disorders, it contained a great explanation of habits and why they make it so hard for us to change. Two sentences in particular made me think about the ways in which therapy only served to strengthen my habit at times: "Dealing delicately and sensitively over a long period of time with things you want to change is nonsense. It doesn't work because you are giving much of your energy to dancing around with and empowering the old pattern."
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