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Interventions in anorexia by cognitive behavioural approaches

The second phase of treatment involves interventions aimed at achieving and maintaining longterm behavioural change. Perhaps the most widely used cognitive behavioural approach was developed by Garner and Bemis. This was divided into a number of phases, the fi rst of which was intended to establish a working alliance with the individual. Garner and Bemis stated that at this time, it is critical that the individual’s core beliefs are not directly challenged, as this is likely to result in a withdrawal from therapy. Instead, the therapist needs to align with the individual, recognize how their weight-control strategies are intended to fulfil important functions for them, and appreciate that these strategies have been partly successful. This may be linked to questioning whether they have achieved everything the individual intended, and evaluating the emotional and physical costs of extreme dieting. The first few sessions may be spent developing a list of the advantages and costs of their anorexic behaviour. There may also be exploration of the deeper schemata underlying this behaviour. Homework assignments may be used to gather data on how events infl uence thoughts and feelings, and to provide opportunities to practise different ways of interpreting weight- and eating-related events. Only once a working alliance has been achieved and the individual is motivated to at least consider change, can cognitive therapy begin. Cognitive interventions may have multiple targets, including modifying inappropriate cognitions and developing autonomy. Emphasis may be placed on challenging perceptual/attitudinal distortions. While these may never change to perceptions of being thin, an awareness of distortions and an acceptance that they have some degree of exaggeration may help change the individual’s willingness to eat. Autonomy may be encouraged by challenging negative cognitions and encouraging the individual to trust their own intuitions and feelings. Cognitive challenges encourage the individual to consider the high emotional cost of their behaviour, and help them to explore some of the more entrenched schemata that underpin this behaviour, such as the belief that body weight or shape can serve as the sole criterion for self-worth and that complete control of one’s body is necessary. Participants in therapy may also be taught problem-solving techniques to help them deal with any crises that might occur more effectively. Studies of cognitive behavioural interventions have shown mixed efficacy, Treasure et al., for example, compared the effectiveness of a cognitive and combined cognitive/psychoanalytic therapy. By the end of the one-year intervention, both therapies proved equally effective, with 63 per cent of participants having achieved a ‘good’ or ‘intermediate’ recovery. Pike et al. found cognitive behavioural therapy to be more effective than nutritional counselling in reducing relapse rates in people recovering from anorexia. The combined percentage of people to drop out of therapy and/or relapse over a one-year period was 22 per cent of those in the cognitive therapy condition and 73 per cent in the nutritional counselling condition. By contrast, the finding of McIntosh et al. suggested that cognitive behavioural therapy may not always prove more effective than some alternatives. They compared the effectiveness of cognitive behavioural therapy, interpersonal therapy and non-specifi c supportive clinical management. The latter was thought to be the baseline against which these active therapies were measured. However, it proved the most effective approach, with 56 per cent of the people in this condition showing signifi cant improvement, compared with 32 per cent in the cognitive behavioural intervention, and 10 per cent of those in the interpersonal therapy. The authors were surprised by these findings, and speculated that the cognitive behavioural therapy may have failed as the cognitive rigidity of the people with anorexia may have made it diffi cult to achieve cognitive, and hence behavioural, change. A further apparent failure of cognitive behavioural therapy  is described in Research box 13. More positively, Carter et al. found a year-long cognitive behavioural intervention to be more effective than usual care in preventing relapse in participants who had already achieved a criterion weight. By the end of the year, 64 per cent of the comparison group had relapsed, while only 35 per cent of the intervention condition had.

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