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jenmichelle October 31st, 2010 07:26 PM

Dichotomous thinking in Anorexia Nervosa

I am wondering if anyone has any suggested dialogue for targeting dichotomous, b&w thinking sometimes seen in clients with Anorexia Nervosa.

I've not been able to find anything in the books I've read or articles I've perused.

Specifically, I'm wondering about the notion that "If I begin to gain weight, I will be fat. Everyone will see me as being humongous."

Well, there is a continuum of weight. It isn't going from being underweight to being fat... the middle portion of the spectrum (appearing healthy, at a normal BMI) is missing.

Any sample dialogue, or questions to ask the client, that'd be particularly effective to get at this?


Rod Whiteley November 2nd, 2010 07:30 AM

Re: Dichotomous thinking in Anorexia Nervosa
Oh, so there are good thoughts that clients are allowed to think, and bad thoughts that must be targeted, are there? Like the old saying, "fight fire with fire", you want to fight dichotomy with dichotomy ;)

Perhaps there is some truth in it. Beginning to gain weight might be the start of a slippery slope that will have consequences the client does not want. I wonder what those consequences might be, what bad things might happen, and how bad they really are.

James Pretzer November 8th, 2010 05:16 PM

Re: Dichotomous thinking in Anorexia Nervosa
If you look back at jenmichelle's post, I don't think she's dichotomizing between "good" thoughts that clients are allowed to have and "bad" thoughts that they aren't allowed to have. She's noticed that certain thoughts turn out to be dysfunctional for her client and that these dysfunctional thoughts are characterized by dichotomus thinking regarding weight gain. This type of thinking is quite common among individuals with anorexia and bulemia and a number of CBT approaches to eating disorders use interventions that target such thoughts.

In terms of how one might target these thoughts, one option is to start by pointing the thoughts out to the client and checking to see if she believes that they are literally true (e.g. "You mentioned thinking 'If I begin to gain weight, I will be fat. Everyone will see me as being humongous.' and those thoughts seem to have a big impact on you. What do you think, is it true that if you gain any weight, you'll be fat and everyone will think you're humongous?"). If the client is convinced that these thoughts are literally true, I'd want to find out what convinces her that these thoughts are true ("What convinces you that you'll be fat if you gain any weight at all?", "What convinces you that everyone will see you as humongous if you gain any weight at all?, etc.) and to see if she is able to recognize and consider evidence that conflicts with the thoughts ("Have there been any times when you gained a pound or two despite your efforts not to gain weight? What happened then? Did you immediately become fat? Did people think you were humongous then?). In doing this, it is important to be trying to help her think it through step by step and draw realistic conclusions. If you're trying to prove a particular point, that will generate extra resistance and be less effective.

With eating disorders, it often turns out that the client knows it isn't literally true that he or she will immediately become "fat" if he or she gains any weight but they persistently tell themselves this anyway. Why? In trying to find out, I might ask something like "So, if gaining a pound or two doesn't immediately make a person fat or humongous, what's the point to telling yourself that it does? What's it supposed to accomplish? What would happen if you didn't tell yourself that it did?" It usually turns out that they are afraid that they will become fat if they do not take extreme steps to control their weight and that these self-statements are an attempt to motivate themselves to restrict eating and/or engage in compensatory exercise/purging/etc. Often they are afraid that a more moderate view will result in their not trying as hard and that they would then gradually gain more and more weight until they eventually become "humongous."

What other dialog/questions would others suggest? Can you think of more promising intervention approaches?

Karen Walsh November 9th, 2010 02:01 PM

Re: Dichotomous thinking in Anorexia Nervosa
It isn't going from being underweight to being fat... the middle portion of the spectrum (appearing healthy, at a normal BMI) is missing.

Perhaps what applies as a "normal" weight for an anorectic is to the anorectic "fat". The goalposts are different, not just because the self perception is different, because the expectation is different. It's a whole different ballpark. Perhaps that is not as Dichotomous as you would think, it's just seeing a different spectrum of grey.

I would suggest that perhaps putting yourself between someone suffering from an eating disorder, and their eating disorder will only widen the gap in your relationship. Anorexia is unlikely to be an enemy to the sufferer, it is their ally, friend, and abusive partner. It may be the world that is the real enemy.

Perhaps it is more helpful to find out a Before Anorexia and an After Anorexia perspective. Why is being underweight so much safer than being normal? Why is normal so frightening?

James Pretzer September 29th, 2011 01:59 PM

Re: Dichotomous thinking in Anorexia Nervosa
This raises an important point, if we put ourselves in the position of trying to make clients do things they don't want to do or trying to stop clients for doing things that they want to do, they're likely to resist us directly or indirectly. It is really easy to end up in this position when working with anorexia, especially if the anorexia has reached the point where it is medically important for them to stop losing weight and put some of the weight back on.

Ideally in CT we take a collaborative stance by negotiating goals for therapy early in treatment and working with the client to accomplish things they want to accomplish. The idea is that a collaborative relationship minimizes resistance and maximizes both the client's involvement in the session and their follow-through sessions. However, this isn't simple to do if the anorexic is convinced that they need to lose more weight while others are insisting that we have to get them to eat more right away.

Certainly, it would be useful to understand what appeals to the client about restricting eating/losing weight and what they fear about eating normally and having a normal build. This could be a good start to developing treatment goals that we can work towards collaboratively.

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