The second phase of treatment, beginning at approximately session 8, is focused on identifying and adapting the patient’s problematic thought patterns. This phase helps disrupt the cycle of overattention to body shape and weight, rigid standards for the self, and extreme adherence to food rules. Cognitive restructuring is a key component of CBT because it reinforces and helps maintain the behavioral changes made and frees the patient from her overemphasis on body shape. Attempts to interrupt problematic behaviors up to this point in treatment have likely provided clues about the patient’s negative thought patterns, existing food rules, and distorted body image beliefs. Comprehensive reviews of cognitive therapy can be found in Cognitive Behavior Therapy: Basics and Beyond (Beck, 2011), and Cognitive Therapy Techniques: A Practitioner’s Guide (Leahy, 2003).

The Thought-Behavior Connection

To help the patient better understand the role of cognitions in her eating disorder, the therapist should explain the thought-behavior connection, which is the way in which automatic thoughts influence one’s behavioral and emotional reactions to situations. All situations include some element of ambiguity that requires interpretation, which is why different people may interpret the same situation very differently. We cannot, for example, know the future consequences of an event or what others are thinking. Depending on our belief system and prior experiences, we insert judgment into the situations we experience. While subjective interpretations of situations are the norm, these interpretations become problematic when they repeatedly contribute to maladaptive behaviors, self-critical judgments, and extreme emotion. Take, for example, the patient who notices a young man staring at her in a department store. How she reacts to this situation is entirely dependent on how she interprets this man’s attention. If, for example, she thinks, “He must think I look attractive; this is my most flattering outfit after all,” she may then smile at the man and feel happy for a short time that afternoon. Conversely, if the patient thinks to herself, “He must think I look so fat in these jeans,” she is likely to feel embarrassed and may ruminate about her appearance for the afternoon. Her original thought may fuel additional negative automatic thoughts, such as “I need to lose weight to be attractive,” “If I don’t lose weight I’ll be alone forever,” “I must start dieting immediately,” and “I will cut out all carbohydrates and fats this week.” The patient’s original thought also determines her subsequent behavior, which feeds back into the situation and can elicit reinforcement of her original interpretation of the event. For example, if this patient scowls at the man in response to his attention, she may then receive an objectively negative response from him that seemingly confirms her original negative belief that men find her unattractive. Identifying these problematic interpretations (or negative automatic thoughts) is an important component of long-term change.

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