Dr Lara Zibarras (PhD) is a psychologist that specialises in helping people with eating disorders, disordered eating and body image issues.
Last Updated on January 15, 2024 by It’s Complicated
Seeking help for eating disorders takes immense courage, so if you are starting your search, then I commend you. In this post I’ll explore how cognitive behaviour therapy (CBT) techniques can work really well for eating disorders such as bulimia.
What is cognitive behavioural therapy (CBT)?
CBT is based on the idea that how we think and what we believe can impact how we feel and behave. So, CBT helps people change their thoughts, feelings and behaviours in a positive way by first recognising how thoughts and beliefs might be impacting their feelings and behaviours.
You are then encouraged to challenge those thoughts and beliefs, examine whether they are true or helpful, and if not, change them. Over time you learn to replace the negative thoughts with those that are more constructive and lead to more positive feelings and also learn how to change how you act in different situations.
In CBT you’ll get “homework” so that you can practise new ways of thinking and doing, outside of your sessions. CBT is also goal-oriented in that it focuses on specific issues and problems – you and your coach or therapist will set clear intentions for what you want to achieve and work towards that goal.
CBT and treating eating disorders
In the context of treating eating disorders, CBT seems to be particularly effective and has been shown to be better than other therapeutic techniques such as psychoanalysis. It’s thought that the reason why CBT is so good for treating people with eating disorders is due to them having distorted thoughts and beliefs about bodies, eating and food.
CBT helps you notice these thought patterns, challenge whether they are true and then replace them with healthier beliefs. CBT also helps you address the behaviours associated with eating disorders, such as binge eating, purging, or extreme dietary restrictions. By modifying thought patterns and behaviours, CBT plays an important role in promoting a more positive and balanced approach to eating and body image. It gives people the tools to overcome various challenges and work towards lasting recovery.
So what techniques can be used, specifically?
Here, I’m sharing 5 powerful techniques, although it’s worth noting that there are many techniques that can be used and these are just a handful that I use with clients.
1. Self-monitoring through journaling
One of the first things I ask clients to do when they come to see me is to start journaling. It’s more than a food diary – yes I’m interested in what they are eating – but more importantly, I’m interested in where they eat, who they eat with, how fast they are eating, and how hungry they are before eating.
Clients are asked to note anything significant around meal times. This helps them become more aware of their eating behaviours, their emotions and any patterns or habits they may have.
Journaling in this way helps identify what leads to certain behaviours – perhaps there’s a specific thought, emotion or situation that triggers a binge, purge, or food restriction.
Together we analyse entries and this helps clients develop coping mechanisms to manage thoughts and emotions that trigger disordered eating behaviours. This practice promotes self-reflection and supports the development of healthier habits and coping skills.
2. Response delay for purging
When I’ve worked with clients who have bulimia, they often want to address the bingeing first. Whilst this is an important part of recovery, addressing purging comes first.
We start to implement a deliberate delay before purging. Bulimia involves impulsive behaviours like purging straight after eating, fuelled by intense emotions or negative thoughts about food or body image. Introducing a pause between eating and purging can disrupt that cycle.
The delay encourages clients to recognise the urge to purge as it emerges, increasing their awareness of it. Then, by consistently practising a response delay, the automatic association between negative emotions and the need to purge is disrupted. This gives clients a sense of control over their actions, rather than just acting on impulse
I also encourage clients to explore alternative coping strategies during the delay – deep breathing techniques, mindfulness, or distraction can help clients to manage the urge to purge. As clients become more successful at delaying purging, it reinforces their sense of empowerment and self-efficacy, highlighting that they can choose alternative ways to cope with negative thoughts and feelings.
3. Exposure to fear foods
Fear foods, often labelled “unhealthy” or “bad”, are those that you’ve either eliminated from your diet or drastically cut down how much you eat.
Eating fear foods often triggers intense emotions such as fear, anxiety, shame, and guilt when eaten. It’s likely a “fear food” if you don’t want to keep that food at home, stress or anxiety heightens when you think about eating that food, you avoid situations where that food is available or you’ve created rules around when and how much of that food you are allowed to eat.
Reintroducing fear foods is a crucial part of recovery from disordered eating and eating disorders. Facing these foods challenges your negative perceptions and allows you to realise that they may not be as harmful as perceived. Although, do remember that this process takes time and might be a slow adjustment, so be gentle with yourself.
Gradually introducing fear foods in a controlled way helps you learn how to cope with any anxiety or discomfort they provoke. Start by slowly introducing the least scary fear foods into your meals and consider pairing them with something you find safe and enjoyable to ease the process.
4. Stress management and coping skills
Disordered eating often becomes the primary way to cope with emotions, and this stops you from fully feeling negative emotions. Therefore it’s important during recovery to develop good stress management and coping skills. Since different strategies work for different people, I recommend experimenting with what suits you best. Your coach or therapist should be able to recommend several ideas for you to try out.
Here are some ideas you might find helpful:
- Mindfulness: There are various mindfulness practices, like focusing on breath or bodily sensations. Mindfulness can also be applied to eating, encouraging you to eat slowly, savour food and be fully present during meal times (and binges).
- Deep breathing: Deep breathing exercises promote relaxation and can be useful during moments of heightened stress or anxiety to calm both body and mind.
- Stress management activities: Activities such as yoga, meditation, stretching, going for walks or spending time in nature can improve emotional well-being.
- Sleep: Adequate sleep is underrated! Lack of sleep contributes to increased feelings of stress and anxiety, disrupts emotional regulation, and it’s harder to cope with everyday challenges. Prioritising sleep is vital for good mental and emotional well-being.
- Relaxation techniques: Finding activities that promote relaxation, whether it’s a warm bath, listening to music, practising self-care, gardening, or engaging in a hobby can help to calm yourself.
5. Relapse prevention
Relapse prevention is something that we start early in the coaching or therapy process. Here we are proactively identifying potential triggers, developing coping strategies and creating a personalised plan to prevent a relapse or return of specific behaviours.
Throughout your recovery journey, recognising your triggers will be key. Triggers can vary hugely among people can encompass emotional triggers, such as feeling stressed after a tough day at work; social triggers, like attending an event with mountains of food; or body image triggers – perhaps buying new clothes that leads to some self-criticism. So you’ll be encouraged to recognise the early warning signs that indicate potential relapse – increased stress, mood changes, negative body image thoughts or negative feelings.
Together, we will develop coping strategies that help you effectively manage triggers and warning signs, so that you don’t resort to disordered behaviours. This will become your personalised relapse prevention plan that includes specific strategies to use when faced with your warning signs.
Throughout the coaching process, you’ll have plenty of time to learn and then practise these skills, to find what works and reinforce their effectiveness. As you progress through recovery, you might encounter new triggers or warning signs and so the recovery plan will adapt and evolve over time.
Having a support network – including friends, family and a good coach or therapist – plays an important role in preventing relapse. It’s also helpful to remember that lapses will happen and they can be framed as “learning events” and each time you come back from a minor setback, you’ll be stronger for it.
Summary
There are many effective CBT techniques to support you on your recovery journey, and the five discussed are just a glimpse into what can be helpful. I highly recommend working closely with a coach or therapist as you navigate your healing journey. If you’re ready to start on the path towards recovery, feel free to reach out for guidance and support.
Sources:
Fairburn, C. G., Kirk, J., O’Connor, M., & Cooper, P. J. (1986). A comparison of two psychological treatments for bulimia nervosa. Behaviour research and therapy, 24(6), 629-643.
Lundgren, J. D., Danoff‐Burg, S., & Anderson, D. A. (2004). Cognitive‐behavioral therapy for bulimia nervosa: An empirical analysis of clinical significance. International Journal of Eating Disorders, 35(3), 262-274.
Poulsen, S., Lunn, S., Daniel, S. I., Folke, S., Mathiesen, B. B., Katznelson, H., & Fairburn, C. G. (2014). A randomized controlled trial of psychoanalytic psychotherapy or cognitive-behavioral therapy for bulimia nervosa. American Journal of Psychiatry, 171(1), 109-116.
Additional Resources
Fairburn, C. G. (2008). Cognitive behavior therapy and eating disorders. Guilford Press.
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