BOOK REVIEW: Treating Bulimia Nervosa and Binge Eating
Reprinted from Eating Disorders Review
May/June 2010 Volume 21, Number 3
©2010 Gürze Books
“Metacognition” usually refers to the variety of processes involved in thinking about how one thinks. These processes include such things as reflecting on the styles of thinking one is likely to deploy under particular circumstances as, for example, when problem-solving, daydreaming, or feeling distressed. Individuals vary in the degree, nature, and capacity of their metacognitive activities, i.e., in how much attention, thought, and reflection they give to actually thinking about their cognitive biases, cognitive styles and other habitual tendencies to think in certain ways (for example, jumping to conclusions, black and white thinking, being preoccupied with details, etc.); how much their stream of attention itself is focused or fragmented; what they think about the origins, purpose and value of their predominant thoughts and schemes; and other self-evaluative cognitive patterns.
Starting with this background, theorists and clinicians have developed a number of strategies focusing on those metacognitive processes believed to regulate the production, intensity and duration of pathological thoughts and pathological thinking processes. Today many types of metacognitive therapy are being used for problems ranging from psychotic illnesses to ADHD. These metacognitive therapies differ considerably from one another--as do the diverse array of cognitive therapies applied to the wide range of psychiatric disorders.
More than two decades ago Adrien Wells, a psychologist who is now at the University of Manchester, and colleagues developed and began to test a theoretical model of metacognitive therapy that they initially applied predominantly to anxious rumination. The primary goals of that therapy included socializing patients to the idea that rumination and attentional monitoring for threat are sources of the problem; helping patients to abandon rumination, including by prescribing the banning of rumination; enhancing flexible control over cognition through the use of attention training; detached mindfulness; challenging both positive and negative metacognitive beliefs about rumination; and modifying negative beliefs about emotion that contribute to rumination/worry and fear of relapse.
More than a decade ago, Myra Cooper, a psychologist at the University of Oxford who’s focused on cognitive behavioral therapy (CBT) for bulimia nervosa and binge eating disorder, and her colleague, Gillian Todd, at Cambridge University, teamed up with Wells to amalgamate their conceptualizations and approaches regarding metacognitive problems in bulimia nervosa and binge eating disorder. The current volume, built around a prototypical case, is the extremely informative and detailed clinical manual that they have developed for these conditions. The approach is a thoughtful morph–with traditional CBT approaches for BN and BED serving as scaffolding upon which the metacognitive work is built. Although many if not most clinicians have otherwise employed these techniques without specifically calling them “metacognitive,” this term may serve a useful purpose in thinking about just how various psychotherapeutic techniques applied to eating disorders fit together.
For clinicians who value CBT as well as other psychotherapeutic approaches, this book is definitely worth reading. Briefly, the clinical work is structured sequentially around a careful assessment; weekly ratings and evaluations completed by clients of their progress, difficulties, and understanding of these events; motivational analysis regarding their attitudes to BN/BED; and socialization into the model by helping them to develop their own case conceptualization (built around a “case conceptualization pro forma” and several worksheets included in their entirety). Next, training in detached mindfulness is introduced, following which the client is engaged in behavioral experiments and self-reflective observations about the negative thoughts and beliefs generated by binge eating under the acronym of the PETS framework (Prepare, Expose, Test, Summarize). In the next phase, using a Dysfunctional Thought Record, clients identify and deal first with their key beliefs about the negative consequences of their disorders and then with their positive beliefs, core negative and positive self-beliefs, and, ultimately with planning for the future, including relapse prevention training.
While much of this will already be familiar to many CBT therapists, there are novel conceptual and practical additions. The precise methods employed by Cooper et al. are detailed in more than 50 pages of valuable appendices . Included are all of their rating scales, and clinical discussions that describe their use. Whether the application of these strategies will ultimately yield more profound and sustaining results than traditional CBT and/or other treatment approaches for BN and BED, and whether particular types of patients are most likely to benefit from these strategies, are questions that have not yet been adequately addressed. While waiting for answers to those questions, clinicians will find much of value in this book, and may decide to enhance their approaches by employing some its rich thinking and clinical lore.