Cognitive behavioural therapy CBT

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CBT treats emotional disorders by changing negative patterns of thought. It is now well established as a key method of helping overcome psychologically based disorders such as anorexia nervosa. Unlike other therapies CBT is very scientific and its approach suits many anorexics for two reasons:

1. CBT is very structured and very logical. This often suits anorexics who like a strict routine and to feel that they are in control.

2. CBT does not try to delve in to the past. Again this suits many anorexics who either feel unable, or unwilling, to address upsetting issues from their past life.

In CBT the patient and therapist will work together to identify problem areas such as the patient's belief that he is fat and stupid. His belief that he is fat and stupid is likely to make him feel low in mood and to withdraw socially. As he becomes more and more withdrawn there is no one to challenge his negative beliefs even if they are not at all true and in reality he is very thin and very clever. It is a vicious circle which, over time, lowers the patients self-esteem and leads the patient to seek more and more comfort from his anorexia. In addition negative thoughts tend to lead to negative feelings, which in turn lead to negative behaviour. Here are three examples:

1. Negative thought: Eating will make me fat. Negative feeling: I am scared of getting fat.

Negative behaviour: I will not eat for the rest of the day.

2. Negative thought: I must exercise constantly to keep thin. Negative feeling: I am scared of putting on weight if I don't exercise. Negative behaviour: I must exercise as much as possible.

3. Negative thought: I am useless at maths.

Negative feeling: I will look stupid if I answer a question in class. Negative behaviour: If I don't join in, in class I will not look stupid.

Once the therapist has built up a trusting relationship with his patient he will start to challenge his beliefs, anxieties and any negative thoughts. He will also encourage the patient to keep a diary of his thoughts and moods in response to day-to-day situations. Initially many of the patient's automatic thoughts will be negative. Over time the therapist will help the patient learn to challenge his negative thoughts and to replace them with positive thoughts. The patient will start to identify which of his thoughts are illogical and irrational. This may take some time, but eventually the patient will start to accept that he is not fat, he needs to eat a balanced diet to be healthy, he needs to exercise in moderation to be healthy and in reality he is quite good at maths.

For Joe a key example of how he challenged his negative thoughts relating to putting on weight was:

• Situation: The re-feeding programme was making Joe put on weight.

• Emotion: Fear and panic over getting too fat.

• Automatic negative thought: I'm going to be too fat to be in the school football team.

• Positive thought: I have been very ill and was too thin and weak to do any sport. I need to put on weight to be strong enough to be in the football team. I need to put on the weight gradually and then to eat a healthy diet to ensure I keep growing. I need to eat enough to build up strength to be able to play a whole football match.

Whilst CBT does not suit everyone it has been found to be particularly useful for treating anorexics. Joe found the logic and structure much easier to deal with than the vague exploratory nature of individual psychotherapy. It also helped that Joe's CB therapist was a sporty young man who Joe could relate to and didn't feel threatened by. Therapy is such an individual thing and there is very much an element of trial and error in finding the right therapist and the right therapies for each individual case.

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