beating your eating disorder (PDF)

 This page intentionally left blank  Beating Your Eating Disorder: A Cognitive Behavioral Self-Help Guide for Adult Sufferers and Their Carers   Beating Your Eating Disorder: A Cognitive Behavioral Self-Help Guide for Adult Sufferers and Their Carers Glenn Waller Consultant Clinical Psychologist, Vincent Square Eating Disorders Service, Central and North West London NHS Foundation Trust, and Eating Disorders Section, Institute of Psychiatry, King’s College London, UK. Victoria Mountford Principal Clinical Psychologist, Eating Disorders Service, South London and Maudsley NHS Foundation Trust, London, UK, and Honorary Research Fellow, Institute of Psychiatry, King’s College London, UK. Rachel Lawson Senior Clinical Psychologist, South Island Eating Disorders, Canterbury District Health Board, and the Anxiety Clinic, Christchurch, New Zealand. Emma Gray (ne´e Corstorphine) Consultant Clinical Psychologist/Service Coordinator, The British CBT & Counselling Service, and Fellow at the Institute of Psychiatry, King’s College London, UK. Helen Cordery Trainee psychotherapist at the John Bowlby Centre, London, UK, and former specialist registered dietitian working with eating disorders. Hendrik Hinrichsen Consultant Clinical Psychologist and Clinical Lead, Sutton & Merton IAPT, South West London & St. George’s NHS Trust, and Visiting Research Fellow, Institute of Psychiatry, King’s College London, UK.  CAMBRIDGE UNIVERSITY PRESS Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo, Delhi, Dubai, Tokyo Cambridge University Press The Edinburgh Building, Cambridge CB2 8RU, UK First published in print format ISBN-13 978-0-521-73904-7 ISBN-13 978-0-511-90948-1 © G. Waller, V. Mountford, R. Lawson, E. Gray, H. Cordery and H. Hinrichsen 2010 Every effort has been made in preparing this book to provide accurate and up-to- date information which is in accord with accepted standards and practice at the time of publication. Although case histories are drawn from actual cases, every effort has been made to disguise the identities of the individuals involved. Nevertheless, the authors, editors and publishers can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. The authors, editors and publishers therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this book. Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use. 2010 Information on this title: www.cambridge.org/9780521739047 This publication is in copyright. Subject to statutory exception and to the provision of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press. Cambridge University Press has no responsibility for the persistence or accuracy of urls for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. Published in the United States of America by Cambridge University Press, New York www.cambridge.org eBook (NetLibrary) Paperback  Praise for Beating Your Eating Disorder “Decades of clinical experience come to light in this plain-speaking self-help text for both sufferers and carers. There’s no sugar-coating here, just a pragmatic and evidence-informed step-by-step approach for gaining control of your own eating disorder. Through the use of rich vignettes and colorful analogies, the authors provide a context for recovery. The chapter on motivation is a unique contribution that allows both sufferers and carers to self-appraise their readiness for change. The book is infused with hope for recovery provided the reader is prepared to dig-in and do the work necessary for a successful self-help journey.” Cindy Bulik, William Jeanne Jordan Distinguished Professor of Eating Disorders, University of North Carolina at Chapel Hill, USA. “Comprehensive and thorough. The information is provided in an approachable and forthright style. The authors clearly describe what is involved in overcoming an eating disorder and encourage the reader to do the necessary work. It doesn’t underestimate the effort it will take, but rather gives very helpful, practical and evidence based information. The book is equally helpful for families and friends of someone working to beat their eating disorder – giving them the support they need to be a powerful ally in recovery. Most importantly, this book gives hope that life without an eating disorder can be lived to the full.” Susan Ringwood, Chief Executive, beat, UK nationwide self-help organiza- tion for sufferers of eating disorders. “This clearly written self-help guide for adults with eating disorders successfully translates the best available treatment we have – cognitive behavioral therapy – into a user-friendly and highly practical self-help approach. It is thorough and detailed without being overly long, and the material is presented in a fresh, interesting way. This excellent book is highly recommended for adult sufferers v  with eating disorders who wish to use a self-help guide for the first step, and hopefully the only step that will be necessary, in overcoming their eating problems.” James Mitchell, Christoferson Professor and Chair, Department of Clinical Neuroscience and Chester Fritz Distinguished University Professor, University of North Dakota School of Medicine and Health Sciences, USA. “The writers communicate in a clear, direct, compassionate and honest voice, enriched by extensive clinical experience, that will help the reader to feel under- stood, to understand what maintains their eating disorder, and to have the courage to experiment with learning to eat healthily again. This is a valuable resource for people with eating disorders considering change, for carers who feel lost, and for therapists who are seeking to help their clients build a foundation for enduring change.” Tracey Wade, Professor of Psychology, Flinders University, Australia. “This is the long-overdue book that adult sufferers of an eating disorder and their carers have been waiting for. It has been masterfully written from a wealth of practical experience and will without doubt become a mandatory resource. It surpasses any of the other self-help guides in quality and scope, and will ensure that those who read it are impelled to act.” Stephen Touyz, Professor of Psychology, The University of Sydney, Australia. vi Praise for Beating Your Eating Disorder  Contents Preface: read this bit first page xi Who is this book for? xi What is this book about? xii Final points before starting xii Who are the authors of this book? xiii Acknowledgements xiv About the authors xv Section 1 Getting started 1 First things first: staying physically safe and well enough to use the help provided in this book 1 1 Who is this book for? 3 “Do I have an eating disorder?” 3 “Does my eating problem really deserve any attention?” 5 “What can I do if I care for or live with someone with an eating disorder?” 7 “Why should I use self-help, rather than getting more formal help from a professional now?” 8 “So what do I do now?” 8 2 The key elements of cognitive behavioral therapy and the self-help approach 10 What is cognitive behavioral therapy (CBT)? 10 The key elements of CBT 10 Your journey through CBT: some landmarks 11 What is CBT self-help? 12 “I’m not sure that I’m ready to change”: a quick word about motivation 14 vii  3 How to use this book 15 Read it all 15 If you are a sufferer 15 If you are a carer 15 Whoever you are 16 Section 2 For the sufferer 17 4 Am I making a fuss about nothing? 19 Some important definitions 19 Myths to dispel 20 5 Motivating yourself to treat your eating disorder 23 Motivational states 23 The pros and cons of having an eating disorder 25 6 Is now the time to act? 29 Life circumstances 29 The balance between the pros and cons of your eating disorder 29 Accepting responsibility for change 30 7 Getting started with CBT 33 Becoming your own therapist 33 What to expect 34 Giving yourself the best chance of success 35 Summary 41 Section 3 The CBT self-help program 45 8 Start here: how to use this program 47 If you are a sufferer 48 If you are a carer 48 Practicalities 48 Anxiety and safety behaviors 49 Final tips on maximizing your chances of success 50 What do I need to get started? 51 The CBT plan for change 52 Building your own road map to recovery 56 9 The practical steps of CBT for your eating disorder 58 What if it is not working? Overcoming “therapy interfering behaviors” 59 Step 1: Developing and maintaining your motivation 59 Step 2: Developing a regular, balanced pattern of eating 60 Step 3: Challenging your thoughts and anxieties about weight 71 Step 4: Addressing negative thoughts and feelings about your body 83 Step 5: Addressing residual difficulties 91 Step 6: Maintaining the gains 92 Where to next in this book? 93 viii Contents  Section 4 For carers 95 10 Am I to blame for the eating problem? 97 Stop blaming yourself 97 Why didn’t I notice before? 98 11 What can I do to support the sufferer? 99 Dealing with emotional distress 99 Should I feel so stressed and impotent? 99 How do I talk to the sufferer? 100 Dangers of collusion 100 What about the rest of the family? 101 What can I do if I am worried about the sufferer? 102 How to ask for help and who to ask? 102 Where can I get information? 102 Getting help for yourself 103 How can I keep the sufferer interested in change? 103 I am a friend of the sufferer: how can I help? 105 Sufferers with chronic disorders 106 Supporting the sufferer while they are following the self-help program outlined in this book 106 Section 5 Transitions into more formal help 109 Before you go any further 109 12 Thinking about getting more formal therapeutic help 111 What has stopped me seeking help before, and what might stop me now? 111 13 Starting the process of getting therapeutic help 114 Who should I talk to? 114 Preparing for your assessment 115 How do I involve my carers 116 What treatment will I be offered? 116 Coping with waiting 117 Attending your first session of CBT 118 14 What to look for in a good CBT practitioner 120 The therapeutic relationship 120 Accreditation/registration 121 Willingness to talk about method 121 Willingness to talk about the process of therapy 123 15 The role of carers in the transition to more formal help 124 What can I do to help my loved one get help? 124 So why is it so hard to help my loved one? 125 ix Contents  Section 6 Letting go of the eating disorder 127 16 The journey of recovery 129 Are there healthier alternatives to my eating disorder behaviors? 130 Who am I if I do not have my eating disorder? 131 What if I can’t make all the changes now? 131 Can I stay “a bit anorexic/bulimic”? 132 What if the eating disorder comes back? 133 17 Relapse prevention 136 Forewarned is forearmed 136 Planning for the future – getting your life back 139 Review sessions 139 A word of warning: the risks of weight loss 140 Dealing with other issues 141 18 Have I done myself permanent damage? 142 Bone structure 142 Fertility 143 Will my eating disorder have had an impact on my children? 144 19 Carers need to move on too 145 Understanding the sufferer’s perspective 145 Who is this new person? 145 What can I do if I think I see the eating disorder returning? 146 Who was to blame for the eating disorder? 146 Conclusion: eating normally again 147 For the sufferer 147 For the carer 147 Appendices 149 References and further reading 189 Index 191 x Contents  Preface: read this bit first Who is this book for? If you are an adult who suffers from an eating disorder, this book is designed to help you overcome your eating problems. It is designed to help you regain control whether you have anorexia nervosa, bulimia nervosa, or an atypical problem (where you have some of the symptoms but do not meet all the criteria for one of those better-known diagnoses). You might have been directed to this book by a clinician (e.g., your family doctor might have recommended it, or a specialist clinician might have suggested that you try it while you wait for more formal treatment). However, many sufferers will never have received a formal diagnosis, but will know that they are not happy with their eating and their associated thoughts and feelings. This book is for you, whether or not you have a diagnosis. If you are a carer, relative, partner, friend or child of a sufferer, this book is designed to help you advise, support, and work with the sufferer as she or he works to overcome the eating problem. This process includes learning how to cope with your own level of stress and concern, because you are likely to be severely affected by the sufferer’s experiences. If you can deal with your own feelings, then you are in a stronger position to support the sufferer. Our aim is to help any adult sufferer to eat normally again, without being plagued by worries about their shape or weight, and without feeling that you are out of control. If that is too much to imagine, then we aim to help you get as far along that path as you are ready to go right now. This book is not aimed at adolescents with eating problems, because the evidence is that such sufferers benefit more from a family-oriented approach. However, there are lessons in here that might be useful ones to add to the family perspective. This book will not be enough for you if you have serious complications from your eating disorder. For example, we strongly recommend that you should seek professional support from your doctor if: • you are very depressed or feel hopeless all the time • you have physical symptoms of your eating problem that place you in danger (see the start of Section 1 on staying safe) • you are using self-damaging behaviors (e.g., self-cutting, binge-drinking) • you have a young child who you fear might be suffering as a result of your eating problems xi  You might still be able to use this book, but only when those other issues are dealt with and you are safe and stable. You might be afraid that going to your doctor will be difficult or embarrassing, but if you go to your doctor with a clear idea of your concerns then she or he has a much better chance of helping you. You will not be the first sufferer or carer that your doctor has seen and there are very clear guidelines that your doctor can use to help in your care and support. One such recommendation is that many sufferers should be encouraged to try a self-help book ahead of any referral to specialist services. A good example is the National Institute for Health and Clinical Excellence (NICE) guideline on eating disorders for professionals, which is available online at: http://guidance.nice.org.uk/CG9/niceguidance/pdf/. There is a linked version of this document for sufferers and carers, which we recom- mend that you read. This version is available online at: http://guidance.nice.org. uk/CG9/publicinfo/pdf/. What is this book about? The self-help approach outlined here is based on the strongest evidence-based approach that currently exists for working with adults with eating disorders – cognitive behavioral therapy, also known as CBT. This form of therapy is not an easy solution to your problems, but it has been proven to have the strongest and/or fastest impact on most types of eating disorder (other than anorexia nervosa) among adults, and is more effective than most other forms of therapy for these disorders. Recent evidence also supports this approach with anorexia nervosa, although the evidence base is not as large. Final points before starting It is important that you remember that there are no miracle cures for eating disorders. If there were then it is pretty likely that you would already have found one that worked for you. Doing CBT is not easy – it is hard work. You can probably bet that the harder you work at it, the more likely this approach is to work for you. So remember, simply owning this book is not the same as using it. Too many of our patients have bought books like this and then waited for them to be helpful, rather than putting them into action. You would be better not to buy this book (or any other) than simply have it sitting on a shelf. For this book to help you, you need to read it and use it. Using this book means learning how to do CBTand applying it to yourself – to take on the role of being your own therapist. There are many tasks in this book that you will find hard, but remember that the reward is that you get to eat normally again and to lead a life where every thought, feeling, and decision is not influenced by what you eat, your shape and your weight. xii Preface  If your eating disorder were an easy problem to solve, you would have solved it already. Eating disorders are real, serious and complex problems. That complex- ity makes them difficult to resolve, but with the right approach it is possible to overcome them. So a key thing to remember is that overcoming your eating disorder is going to be a complex and challenging task, and that it will require you learning to eat healthily again in order to succeed. That will mean working to develop an appropriate structure to your eating, and then changing the content of what you eat. Your thoughts, feelings, relationships, and motivation will all be import- ant, but working on them without working on your eating (from the beginning) is unlikely to help you to escape your eating disorder. Who are the authors of this book? We are clinicians with many years of experience in working with the whole range of eating disorders, using CBT to help people with eating disorders to eat healthily and to feel good about themselves. Our goal in writing this book is to make this approach available to many sufferers (and their carers) who find it difficult to get clinical help, for whatever reason. xiii Preface