Cognitive therapy works to change the way the patient thinks, not just about food and eating, but about herself and her world. Of course, thoughts and actions are intertwined. Thus behavioral therapy and cognitive therapy are in a sense two sides of the same coin. Changing distorted ways of thinking can allow healthier behaviors to emerge.
Patients often resist change because they have adopted faulty ideas about food and beauty. Our culture creates and spreads many of these ideas. Over time, patients accept these notions as truth and stop questioning whether they are valid. Cognitive therapy identifies and challenges the characteristic thoughts that reinforce disordered eating.
The food diaries are a good place to start, since they record a woman’s thoughts about eating. We can explore these thoughts during therapy sessions.
For example, I recently worked with a patient on the need to eat three regular meals a day. She agreed to try, but at home, alone, she hesitated putting the rule into practice. In her diary she noted that whenever she faced the need to eat on such a schedule, she always thought, “If I eat that much food I will get fat.” Another patient reported that every time she stepped on the scale, she automatically thought, “I am so fat that everyone must hate me.”
Automatic thoughts may strike when a patient feels angry or suffers rejection. Such thoughts usually center on feeling or looking fat, the fear of losing self-control, or the need to diet. Sometimes the thought takes the form of a mental image. One patient said, “Whenever I eat, I imagine I’m a pig wallowing in a mud-hole. Dozens of people stand at a fence watching me gorging on my slop.”
Once we identify these recurring thoughts, we can examine them carefully. The first step is to reduce the thought to its essence. I may ask the patient, “Are you feeling fat because you are afraid that others may see you this way?” Or I may ask, “Do you think that feeling fat is your way of dealing with anger? Does it spring from your belief that you are a worthless person?”
The next step is to gather any evidence that either supports or contradicts the patient’s automatic thoughts. For example, if the patient thinks she is fat, we determine whether she has actually gained any weight recently. If she has, then of course her thinking has some basis in reality. If not, her feelings may represent a kind of substitute for her unacceptable feelings of anger.
Once we’ve identified these characteristic thoughts, the patient and I can begin the search for more valid ways of thinking. For example, we try to turn the false notion “I am fat” into the reality: “My weight is the same, but today I’m wearing a pair of jeans I bought back when I was unhealthily underweight. I’m not fat; my clothes are too small.”