Bulimia nervosa is an eating disorder, characterised by patterns of restrictive eating, binge eating and purging (i.e. by taking laxatives or self-induced vomiting). The National Institute for Health and Care Excellence (NICE) recommends that Cognitive Behavioural Therapy (CBT) is one of the most effective psychological treatments for bulimia. We asked two RSCPP therapists to explain what CBT is, and how it can be used to treat bulimia nervosa.
CBT focuses on the effects of maladaptive beliefs, thoughts and viewpoints on your emotions and behaviour. The assumption is that situations or events may be relatively neutral, however, it is the meaning or interpretation that you attach to that event or situation that determines your reaction. Your underlying beliefs about yourself, your relationships to others, and your positions in your world are thought to influence your cognitive processing (i.e. how you think). These beliefs are constructed during early development, as well as through significant events experienced throughout the development process. This then becomes the lens through which you view yourself in relation to situations, events and relationships.
CBT treatment posits that, whereas people without eating disorders evaluate themselves on the basis of their perceived performance in a variety of domains of life (e.g. the quality of their relationships, work, parenting, sporting ability, etc.), people with any type of eating disorder, including bulimia, judge themselves wholly in terms of their eating habits, shape or weight (often all three) and their ability to control them. CBT for bulimia nervosa focuses on your excessive concern about body weight and shape, binge-eating, and inappropriate compensatory behaviours, using a combination of cognitive and behavioural strategies to help you modify your distorted thoughts, beliefs, and attitudes (e.g. 'I'm no good because I'm fat') that maintain the disorder. Treatment is aimed at helping you explore and improve beliefs about yourself, eliminate dietary restraints by establishing a pattern of regular food intake, and eliminate binge-eating and purging behaviours.
A brief summary of a CBT formulation for bulimia would involve understanding your levels of low self worth and how this has come to be located predominantly in how you look. An exploration of your dietary rules would follow, and the consequential negative mood states when these rules are broken through bingeing. This pattern would then result in purging in the form of vomiting, laxative use, diuretic use or over-exercise, which in turn, results in further negative emotions such as guilt and shame. The maintenance of this cycle therefore reinforces your negative self image and then maintains the vicious cycle of bulimia. CBT focuses primarily on these processes that maintain your eating disorder. Treatment involves psychoeducation, behavioural experimentation and cognitive restructuring.
The NICE guidelines recommend 16-20 sessions over a 4-5 month period. This, however, is dependent on your level of motivation for change, as well as whether you have any co-existing mental health issues, such as anxiety, depression, alcohol or drug-dependence, trauma, etc.
CBT is suitable for anyone who's interested in a more active, change-focused treatment modality. If you are affected by bulimia, you may generally feel out of control, not only in terms of your eating but in other areas of your life too. CBT is helpful in that it provides a safe, containing structure from which to experiment with changing your behaviours.
CBT has been found to be effective in the treatment of bulimia, can result in a significant reduction of symptoms, such as binge eating, purging and other compensatory behaviours, and these effects are generally seen to be maintained over time.
All therapists on rscpp.co.uk are accredited, registered or chartered by a UK professional body. Therapists who offer Cognitive Behavioural Therapy will in addition have completed training in cognitive behavioural practice.
You can enquire whether the therapist has experience in working specifically with CBT for eating disorders such as bulimia, and what this treatment involves. The therapist may then describe the use of the CBT formulation for bulimia and provide some examples of how treatment progresses. This would involve exercises like keeping food diaries, engaging in behavioural experiments and cognitive restructuring. CBT therapists working with eating disorders would also weigh their clients on a regular basis, work with dietitians, and request blood tests from your GP, as well as receiving updates about your physical health when necessary.