The majority of patients with BN will, at least once during the course of treatment, find it difficult or anxiety provoking to fully comply with treatment recommendations. Rather than labeling the noncompliance as resistance or lack of motivation, the cognitive-behavioral therapist may find it more useful to conceptualize the patient’s noncompliance as a normal, understandable reaction to the prospect of change. In fact, some noncompliance (e.g., continued purging, failure to eat throughout the day, or intense fear of weight gain) simply reflects the symptoms of BN. It is also useful to consider that treatment roadblocks (e.g., continued bingeing or midtreatment setbacks) can be equally frustrating for patient and therapist.

There are several particularly common roadblocks that occur during CBT for BN (see Table 4.2). Roadblocks may stem from patients’ fears of gaining weight, of losing control, of setting themselves up for a binge, or of breaking a long-standing food rule. Patients who do not fully accept the cognitive-behavioral model of BN may intentionally attend to some interventions (e.g., those that will disrupt bingeing) while ignoring others (e.g., those that address dietary restriction and food rules). Patients are often reluctant to give up those aspects of their disorTABLE 4.2. Common "Roadblocks" in Bulimia Nervosa Treatment

• Frequent tardiness or missed sessions

• Reluctance to keep daily food records

• Failure to eat planned, regular meals and snacks

• Not monitoring and/or challenging automatic thoughts

• General homework noncompliance

• Patient feels hopeless and/or discounts treatment progress

• continued vomiting or laxative use

• continued dietary restriction

• Lack of symptom improvement

• resumption of bingeing and purging after a period of abstinence

der that provide them with the illusion of control and safety. Perfectionism is common among patients with eating disorders, as is a strong desire to obtain approval from others, including their therapist. Patients may, therefore, experience shame when unable to meet their own particularly high expectations. Patients often attempt to hide perceived failures from their therapist (e.g., choose to discontinue food records completely rather than write down a single binge-purge episode), or they take an all-or-nothing approach to treatment compliance (e.g., experience an urge to binge, subsequently feel that treatment is not working, and therefore give up on completing thought records).

Expressing surprise at the first sign of noncompliance is often useful, as is reviewing with patients the importance of homework for solidifying skills development and behavioral change between sessions. Food records and thought records are particularly important for symptom improvement. Patients often resume compliance after a reminder that CBT is deliberately active and collaborative, and that symptom improvement is contingent on homework completion. It is also helpful to review the cognitive-behavioral model of BN and to underscore the necessity of addressing all symptoms. Another quite basic, and often effective, intervention for noncompliance is for the therapist to simultaneously normalize difficulties with homework compliance and to explore patients’ reasons for not practicing interventions between sessions. This provides patients with an opportunity to openly vocalize any fears or misunderstandings about the interventions.

Other common therapeutic interventions can be effectively applied to treatment roadblocks and, when addressed soon after they arise, can provide an opportunity to bolster motivation for change, to practice problem solving, and to challenge relevant dysfunctional cognitions. These interventions include the following.

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