Your Teen And Cognitive Behavior Therapy

Chris Haltom, Ph.D.
EDsurvivalguide.com

You have probably heard of cognitive behavior therapy or CBT. Most psychotherapies for teens and adults with eating disorders receive some form CBT as part of their treatment. Even most family work includes some form of cognitive behavior intervention. The easiest way to understand CBT for eating disorders is to consider the thoughts and behaviors that characterize eating disorders. Then think about the psychotherapy and counseling work required to challenge and change those thoughts and behaviors.

One example of CBT skills taught to those in eating disorder recovery is called "Catch it, challenge it, change it." (Remuda Ranch, 2007). This intervention or skill starts with "catching" a negative, distorted thought related to a particular situation. A typical situation a teen with an eating disorder might react to in a negative fashion is consuming a healthy, well-balanced dinner. She or he might say to her or himself, "I have eaten dinner and now I am fat and disgusting." "Catching" this toxic thought is the first step. Developing awareness of thoughts present in the mind is a prerequisite skill. For example, someone who has developed this skill might say to themselves, "stop and look at what you are thinking right now".

It is also useful to figure out what feelings a person is experiencing when having a toxic thought. Usually, distorted eating disorder thoughts are associated with uncomfortable feelings like sadness, anger, anxiety, or self-loathing.

After "catching" a self-defeating thought or message the next step is to "challenge" the toxic thought. This is done by stating the untruth of the toxic message. Another alternative is to ask questions that either help discover the truth or help find a more a realistic replacement thought or thoughts. A challenge to the fat-because-of-dinner thought might be,"What is the truth about being fat and disgusting because of eating dinner?" In order to get started a therapist or counselor might first role model this skill by asking your teen a challenge question like "What evidence is there that you are fat and disgusting because you ate dinner?" Later teens are expected to learn to question themselves with their own challenge questions.

Finally, "changing" the thought takes the form of finding a replacement thought or alternative interpretation. It is important that the alternative thought is not pie-in-the-sky positive. The alternative thought needs to be rational, realistic and believable to the person challenging themselves. For example, when teens tell themselves they are ugly and disgusting because of eating a meal, they often feel shame, embarrassment, and self-loathing. When they give themselves realistic alternatives such as "one meal does not cause people to change their body size or appearance" or "eating a balanced meal will support my recovery" resulting feelings are often positive and self-esteem is improved.

Parents and carers often find it helpful to understand the self-defeating thinking and behaviors their teens are struggling with. Most carers have had the exasperating experience of encountering entrenched, negative beliefs in their children, often realizing that a head-on corrective approach deosn't work. Beliefs like 'mayonnaise will make me fat' or 'sitting still will make me gain weight' are not so easily caught, challenged or changed. Developing cognitive -behavior skills takes patience. It takes intentional, incremental identification and challenge of negative thoughts and behaviors unique to each teen struggling with an eating disorder.

Parents and carers often have their own cognitive-behavior re-training to perform on themselves. The incredible stress that eating disorders create in the home can lead to carers having their own negative or unrealistic thoughts. For example, in an effort to entice their child to eat, parents might buy diet foods or allow excessive exercise. This is born out of a desperate belief that these approaches will get their child to eat or stop purging. In turn, it can be hard for parents to accept new beliefs such as 'consistent, balanced eating is non-negotiable' or 'some foods that the media have labeled "bad" are fine in moderation.' They may find themselves challenged by the knowledge that eating disorders are illnesses, not choices on the part of a willful teen.

Teens with eating disorders may try to negotiate permission to skip or skimp on a meal, delay a meal or substitute diet foods for regular foods. Parents learn to "catch" their temptation to yield to eating disorder thinking in their offspring. They might "challenge" themselves with the question , "Am I accommodating the disorder?" Finally, parents might "change" their thinking and behavior by saying to their teen, "I am sorry the eating disorder is giving you such a hard time - let's try to work on fighting this together."

Here are some TIPS for carers about catching, challenging, and changing eating disorder thoughts and behaviors:

1. Distorted beliefs about food, eating, weight and/or size are almost always part of the struggle of those with eating disorders. Read about eating disorders. Ask open-ended (not "yes" and "no") questions to your teen about their eating disorder experience. LISTEN TO THEIR REVELATIONS ABOUT THEIR INNER THOUGHTS.
2. It is usually best NOT TO DIRECTLY CORRECT DISTORTED PERCEPTIONS. Rather, the most effective change occurs when the corrections come from the person with distorted beliefs. You can assist by supporting honest self-reflection and self-questioning.
3. Sometimes teens with eating disorders will ask you to correct their toxic thoughts because they are seeking reassurance. For example, a teen might ask, "I am not getting fatter, am I ?" Be careful not to provide reassurance for this kind of obsessive, eating-disorder-driven question. Any reassurance you provide will only temporarily satisfy and will inadvertently reinforce eating disorder thoughts. Distorted thoughts about getting larger may not change until your teen is recovering. However, IT IS FINE TO EMPATHIZE WITH THE ANXIETY BEHIND A QUESTION about size-reassurance or other worries your teen may have.
4. Think of your own beliefs about eating disorders, nutrition, body image, weight, and recovery. Try to UNCOVER ANY DISTORTED OR FALSE BELIEFS, CHALLENGE THEM AND CHANGE THEM. For example, a challenge to the false belief that "It is my fault my daughter (or son) developed an eating disorder" might be "no one is to blame for eating disorders" or "it is an illness and no one caused it."
5. An important part of CBT is collaboratively setting goals with both teens with eating disorders and their families. BE INVOLVED IN SETTING GOALS FOR TREATMENT. By doing so you will establish a a strong foundation for cognitive-behavior changes that are lasting.
6. As part of goal-setting, continue to provide treatment professionals with HELPFUL OBSERVATIONS of your teen's thoughts and behaviors at home. This collaborative effort with treatment team members assists in identifying key thoughts and behaviors that need addressing in treatment.

SUMMARY:

Cognitive behavior therapy interventions have been adapted for anorexia, bulimia, binge eating and partial syndrome eating disorders in adolescents. A manualized appaccomodatinglication of CBT for adolescents with bulimia has been developed (Lock, 2005). Christopher Fairburn and his colleagues have long been providing specialized treatment protocols for those with bulimia and binge eating disorder. It is useful to understand what cognitive behavior therapy is and how it might help your child in treatment.

REFERENCES

Fairburn, CG, Cooper, Z., and Shafran, R. (2003) Cognitive behavior therapy for eating disorders: a "transdiagnostic" theory and treatment. Behavior Research and Therapy, 41: 509-529.

Lock, J. (2005) Adjusting cognitive behavior therapy for adolescents with bulimia nervosa. American Journal of Psychotherapy., 59: 267-281.

Remuda Ranch (2007) Recovery skill taught to adolescent clients as part of their residential treatment: Hope skill: "Catch it, challenge it, change it", Changing negative messages.

Wonderlich, S., Mitchell, J., Zwaan, M., and Steiger, H. (2008) Annual Review of Eating Disorders, Part 2 - 2008, Academy of Eating Disorders. New York: Radcliffe Publishing.

Dr. Haltom will be presenting at the 18th Annual Renfrew Foundation Conference for Professionals in Philadelphia (www.renfrew.org) on Nov. 16, 2008. Please stop by to say hello.