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ABC theory of emotional disturbance
In bulimia nervosa, the emotional `baggage' such as anxiety, guilt, anger, etc. and various practices that help to prevent weight gain and the change of body shape are the consequences (C) of the client's interpretations of and assumptions about (B) an activating event (A). The activating event, for example, could be that the client has broken her dietary rules or that the client has put on some weight. Fairburn (1997) points out that these thoughts are largely the result of the way the bulimic interprets the assumptions made about the breaking of her dietary rules or putting on some weight. It is therefore important for the therapist and the client to work collaboratively to target what overvalued thoughts (negative self-beliefs and rules) are causal to the bulimic symptoms. Using a vignette as an example, the remainder of this paper will illustrate how to target the specific content of thoughts, and inform the conceptual and practical issues underpinning a range of evidence-based techniques. These techniques will facilitate the change at both levels of cognitions and behaviors.
The vignette: the client
She described herself as a reasonably successful person, working for a large international company that required her to travel extensively abroad. She set herself extremely high standards and was profoundly dissatisfied when she did not meet them. This perfectionism was seen in many aspects of her life, and it was applied to her dieting thereby accounting for its intensity. She described herself as a sensitive person who needed to be accepted by `virtually' everybody in order to feel secure in herself. Other identified problems were low self-esteem and non-assertiveness.
Cognitive assessment: a binge-purge situation
T: What was so anxious-provoking in your mind about `eating too much' in the restaurant?
Rachel's need to take dietary control seemed to be more related to the evaluated beliefs of rejection, awfulizing and self-worth. People who have inferred beliefs such as fat, ugly and disliked by people do not necessarily end up with bulimia nervosa. Dryden (1995) concludes that inferred beliefs contribute to, but do not determine emotions. Evaluative beliefs, on the other hand, cause both intense emotional and behavioral reactions to negative events (Safran et al., 1986; Ellis, 1994) and may undermine the client's motivation or sense of adequacy or self-worth (Beck, 1995; Fennell, 1999).
Greenberger and Padesky (1995) suggest that it is important to identify and examine them so as to facilitate sustainable emotional and behavioral changes. Barton (2000) presents an argument that it is important to differentiate between negative (inferred beliefs) and depressive thinking (evaluative beliefs) in relation to depression. For example, negative thoughts or inferred beliefs such as `I am not much good at sport'; `The world is facing difficult social problems'; `Next week is going to be really stressful' clearly will not cause depression. Cognitive behavior therapists that inadvertently challenge thoughts or inferred beliefs that are less central (or unrelated) to depression will result in little therapeutic gain. Similarly, challenging thoughts or inferred beliefs that are less central to bulimia nervosa will at best provide some symptoms relief and at worst prolong suffering or increase the likelihood of relapse or recurrence. For example, helping the bulimic to recognize (or even to accept) that she is neither fat nor ugly can result in a little therapeutic gain.
The intensity and rigidity of the dieting seen in Rachel could be understood as an expression of the combined influence of two general cognitive characteristics, perfectionism and dichotomous thinking (thinking in black and white terms). According to Fairburn (1997,p. 212), `patients with bulimia nervosa tend to be perfectionist by nature. This perfectionism is seen in many aspects of their life, and it is applied to their dieting, thereby accounting for its intensity'. They set themselves extremely high standards and are profoundly dissatisfied when they do not meet them. This important point is highly relevant to the therapeutic work with bulimia nervosa. Perfectionism is rigid by nature and is often expressed in the form of `must', `should', `have to' and `ought to'. Rigidity is the source of psychological and emotional problems (Ellis, 1994). They overestimate how bad it is when expectations are not met, and this leads to emotional distress such as anger, anxiety and guilt (Bums, 1990).
In the case of Rachel, her perfectionism was, `I must be able to be in control of my food intake'; `I should be able to cope and do well in my job'; `people ought to appreciate and praise my achievements'; `my house has to be clean and spotless'. Her dichotomous thinking was -- `if I lose dietary control, I will be rejected by others'; `If I am rejected by others, it will be terrible and I am no good and unlovable'. In order not to be rejected by others and to feel worthy as a person, Rachel was trying hard to be perfect in many aspects of her life, including her food intake. The combined influences of perfectionism and dichotomous thinking were found to be consistent in her cognition in other situations, from work, social and domestic chores. It was the fear of rejection or being disliked and being worthless that was driving her to set herself extremely high standards in many aspects of her life, including her diet. Targeting thoughts relating to rejection, sense of self worth and awfulizing are likely to result in better treatment outcomes. Figure 2 illustrates the cognitive behavioral conceptualization in the maintenance of bulimia nervosa.
Disputing dysfunctional thoughts: rejection, self-worth and awfulizing
Rejection and self-worth
Rational and pragmatic arguments are useful in helping the client to give up the dichotomous thinking about rejection (Ellis, 1994; Dryden, 1995). Rational arguments help the client to understand that rejection (or being disliked by some people) is the experience of every fallible human being. There is no law of the universe to say that jut because people don't like it, it mustn't happen. Rejection happens to people at different times in their lives. It is important to note that the rational disputing itself is not about empirically evaluating the evidence that the client might have but on whether this kind of dysfunctional thinking (`must' and `should' statement, dichotomous thinking) is rational or not. Pragmatic arguments, on the other hand, are to draw the client's attention to the consequences of holding on to the dysfunctional thinking. It is a supplement to the rational argument. The client often is not consciously aware of the implications of holding on to the dysfunctional thinking. The implications can be related to his/her personal life, health status, work performance and interpersonal relationships (Fairburn et al., 1993). The following therapist/client dialogue illustrates the rational and pragmatic arguments. This came from the author's clinical work (T = therapist, C = client):
T: Why mustn't people reject you?
Two important concepts are illustrated in these rational and pragmatic dialogues. The first is about internal versus external locus of control. Dyer (1992,p. 149) states that `the internal locus of control person puts the responsibility for how he/she feels squarely on his/her own shoulders', whereas the `external person' assigns responsibility of his/her emotions to someone or something. Emotions or feelings are the result of how and what the person perceives himself/herself in relation to the others. Distinguishing the differences between internal and external control may help the client to take on the responsibility for his/her emotions and to question his/her thoughts about self-worth. This could raise his/her motivation and self-confidence in the change process.
The second concept is about the use of two sets of rules that the client practices: one is for herself and the other for her daughter. Lam (1997,p. 1206) suggests that an effective strategy is to shift the client's drinking into a state of objectivity in which not only is disputing effective but also helps the client to develop a higher level of abstract drinking which he/she could relate to his/her personal experience/problem. The `daughter's technique' helped to psychologically move Rachel away from her dysfunctional drinking (she will be no good and a failure if rejected or disliked) into a state of objectivity relating to her daughter's problem. This helped to facilitate the development of objective and rational thinking, which would act as a catalyst to reflect on the irrationality of her dysfunctional drinking.
Beck (1995,p. 158) suggests that `a cognitive continuum technique is often useful with clients displaying dichotomous thinking'. This technique is effective not only in modifying the beliefs that reflect polarized thinking but also in facilitating the recognition of the middle ground. The following dialogue illustrates the use of this technique:
T: How strongly do you believe that it is awful (or terrible) to be rejected by others? -- 100% is the most awful and 0% is not awful at all.
Working on behavioral change
Collaboratively, an experiment was devised in which Rachel was going to change her eating habits/pattern, put on an agreed amount of weight (6 pounds) and dress `suitably' for work with no make-up (she always dressed immaculately). This evidence collecting experiment was to test the hypothesis (Rachel's belief) that the change in body image/weight would lead to being disliked and rejection. Lam and Cheng (1998,p. 1148) argue that `a homework assignment, in a form that was linked to the session, serves as a mechanism in facilitating the client to think about his/her thinking (overvalued)'. What is important in this experiment is the need for the client to recognize and accept the rationale, and understand that `dietary control' is not going to be taken away from her. Fairburn and Walsh (1995) state that bulimic's need to have strict control over their eating. Losing control can be interpreted as a threat to their self-worth. Recognizing and accepting the rationale for the experiment, together with the reassurance that dietary intake is still in their control, will help to increase the level of compliance with the agreed therapeutic tasks.
Initially feeling surprised at her 3-week findings that many of her colleagues and friends had hardly changed their behavior towards her, the realization that the change in body weight and image did not result in rejection, had brought a sense of relief to Rachel. This process of collecting evidence was enhancing Rachel's conscious awareness that her overvalued thought was not only distorted and unhelpful but was also not based on fact. This would increase her confidence to agree to a stable pattern of regular eating and to be more flexible in the type of food she ate, thus helping to eliminate the need for binge eating. Fairburn (1999) believes that replacing binge eating with a stable pattern of regular eating is one of the major aims in the treatment process.
Overholser (1993) suggests the use of systematic questioning to help the client benefit from this exposure or experiment. For example, `What do you think you have learnt from this exercise?"What conclusion can you draw from your observation of peoples' behavior?'; `How is it logical to say that just because of the change in your body weight/image people will reject you?'; this type of questioning could cultivate a more reality based thinking, thus facilitating more effective problem solving strategies.
In bulimia nervosa, working on the client's perfectionism and approval seeking behavior is essential and is an important aspect of the therapeutic change. The client often believes that unless things are performed perfectly he/she is no good or a failure; and that if his/her behavior is not recognized and praised by others then he/she is not a lovable and competent person. Failing to meet these expectations (or to have their expectations met) not only affects his/her self-worth but also generates intense emotional and behavioral reactions (Fairburn et al., 1993b; Beck, 1995). Techniques that are found to be clinically effective in working on perfectionism and approval-seeking behaviors include cost and benefits analysis, assertive training, role-play and stress inoculation training, etc.
The suggestion to initially target the overvalued thoughts (negative self-beliefs and rules) that are causal to bulimia nervosa is clinically important. Tiffs would ensure better treatment outcomes. Cooper et al. (1998,p. 228) believe that `for treatment to be successful and to prevent relapse it may be important to address both negative self-beliefs and underlying assumptions'. This paper proposes that using a recent binge-purge situation as a `baseline' will help to identify these overvalued thoughts. Using the identified thoughts from the baseline, the therapist and the client can look for any consistencies in the client's overvalued thoughts (negative self-beliefs and rules) in other situations. These situations could be work, social and/or interpersonal. Returning to Rachel, her overvalued thoughts (rejection, unlovable and awfulizing) were found to be consistent in a range of situations. These greatly affected her sense of self-worth and propelled her to strict dietary control, perfectionism and approval seeking behaviors.
Once the client is able to understand and accept that these overvalued thoughts are central to her psychological problems, in a range of other situations and not just associated with diet, tiffs will provide her with the confidence and motivation to try to empirically validate these thoughts. Tiffs would further shift her overvalued thoughts, as her `observation or the data collected' has failed to support her thoughts about the personal implications of body weight and shape. The recognition that it is not awful or terrible to be rejected or unloved is an added incentive for the client to continue testing out whether or not rejection is the result of the change in body weight/image. This will help the client to understand that there is an array of contributing factors to a person being rejected (or unloved), not just body weight/image. The suggestion that the role of behavior in the maintenance of psychological difficulties and problems is also clinically important. Behavioral changes should, therefore, go beyond just helping the client to adopt a stable pattern of regular eating. Assertive and social skills training and work on perfectionism will also help to modify the client's negative self-beliefs and underlying assumptions (rules).
The process of behavioral changes (conducting the empirical study/experiments) itself not only helps the client to collect evidence/data to validate these thoughts but also helps him/her to integrate, synthesize and evaluate different sources of information. These skills will be invaluable in helping the client differentiate thoughts (overvalued thoughts) from the facts.
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