In several earlier posts, we have discussed the nature and treatment of binge eating, with a particular focus on dialectical behavior therapy. Today, I would like to discuss another empirically based approach to the treatment of binge eating, Fairburn's cognitive-behavioral approach as explained in the self-help manual Overcoming Binge Eating. In this book, Fairburn provides a significant amount of research based educational information regarding the nature of binges, vulnerabilities to binges, and methods and rationale for treatment. The remainder of the book is a step-by-step instruction for self-help that mirrors and can be used in conjunction with an alternative book intended for therapists, Binge Eating: Nature, Assessment, and Treatment. Fairburn does not advocate individuals with clinically significant difficulties with binge eating avoiding therapy, but rather seeks to provide a science based alternative to the well-intended but inaccurate and ineffective self-help books that flood the market and fill the shelves of bookstores internationally.
Fairburn explains that CBT for binge eating involves three distinct stages that should be conducted sequentially. The stages are further broken down into six steps and I will explain each step in detail momentarily, but as a quick summary, treatment can be explained as follows. Initially, the emphasis is on education and observation. The goal at this point is to develop a clearer understanding of binge eating and to assess accurately the degree to which it is impacting your life. The second stage involves changing specific problematic behaviors and involves exposure to feared and banned foods and the development of skills for managing the stress that often precedes and prompts binge eating episodes. These first two stages are the active ingredients of treatment, functioning to diminish symptoms. The final stage involves planning for the future so as to decrease the changes for relapse. Importantly, as you progress through each stage/step, earlier activities are continued. In other words, beginning Step 2 does not mean discontinuing Step 1, but rather building upon what are you already doing.
The initial step begins with simple observation, otherwise known as self-monitoring. Your first goal is to write down everything you eat, what time you eat it, where you eat it, whether or not you vomited or used any other compensatory behavior after eating, and any contextual comments you feel would be useful. The book itself provides a sample food monitoring worksheet and instructions for filling it out. Fairburn mentions that, initially, you may feel resistant towards this step because it seems daunting, it has proven ineffective in the past, or you are worried that it will make you feel ashamed and even more preoccupied with food. He counters these points by assuring that this approach will be focused on how to overcome this behavior, but that doing so requires an honest and accurate understanding of what is happening and in what context. In other words, in order to change something, you first need to understand what it is.
Importantly, in this initial step, the goal is not to change your eating behaviors. Remember, at this point, we are observing ourselves. Certainly you want to stop binge eating and treatment will help you do so quite quickly, but we first need to understand precisely when you are most vulnerable and how your behaviors tend to unfold in order to gear treatment particularly towards these problem areas. Change will come very soon, but first simply observe.
The food monitoring record serves numerous functions. In addition to providing you with an accurate description of your behavioral patterns, it serves as an honest record of progress as treatment progresses. Often during treatment, people have a tendency to dismiss progress or deny it entirely. When you have objective data in front of you, however, this becomes more difficult. As such, it is important not to throw these records away. A good method for this is to keep a folder of all materials relevant to treatment that can easily be kept private but is not likely to get lost.
The second component of Step 1 is weekly weighing. As Fairburn explains, individuals who struggle with binge eating are often highly preoccupied with their weight. As a result of this preoccupation, such individuals often weigh themselves repeatedly, sometimes many times in a single day. Alternatively, some individuals become so fearful about their weight that they avoid scales entirely even though they do not stop thinking about it. As a result, they are left with judgmental thoughts about weight but no data to test their theories about themselves. These tendencies are problematic for several reasons. Primarily, the issue is that weight tends to fluctuate even within a single day, thereby making any single reading or small shift in weight difficult and potentially impossible to interpret. Fairburn's suggestion, therefore, is to have a planned time once per week for measuring your weight. Importantly, because weight shifts so often, he warns that you should not place much emphasis on shifts even from one week to the next. Instead, you should make a graph and look at trends over the course of three or four weeks in order to have a more reliable reading of changes in weight. Fairburn's program is not a weight loss program, so the goal when beginning this should not be a substantial change in weight; however, a shift away from binge eating and towards a healthier diet is likely to result in positive changes, so Fairburn wants to ensure that changes are understood properly.
Moving on to Step 2 requires that you accomplish the goals of Step 1. To meet this qualification, Fairburn suggests that you wait until you have 6-7 good days in a single week. A good day, at this point, is defined by successfully completing your food monitoring worksheet (completely - not partially). Once you have met this criterion, you are ready for Step 2. For each subsequent step, the criteria for a "good day" change, so refer to the book in order to fully understand this process.
Meals should be spaced apart by three to four hours and eating should be contingent upon timing, not bodily sensations of hunger or satiety. At this point, you are training your body to respond to a different pattern of eating and training yourself to respond differently to bodily cues. Do your best to stick to this schedule, even if it means adjusting other plans when possible. If you fall off of the schedule, simply do your best to return to the schedule as quickly as possible.
Be certain to plan your next day's mealtimes at the end of each day. Sticking to a schedule will be significantly easier if you do not have to make the schedule up on the fly. Additionally, having a plan already formulated will make it easier to adjust to the unpredictable day-to-day events that might otherwise interfere.
Additionally, at this point the plan is not the change what you eat, but rather how you eat. Fairburn points out that a regular pattern of eating tends to quickly reduce the frequency of binge eating episodes. As such, it is unusual for the introduction of regular meals and snacks to increase weight. In fact, it is entirely possible for the opposite to occur.
At this point, Fairburn also offers some advice to help maintain a regular pattern of eating and avoid binge episodes. These measures are not intended to be permanent life changes, but rather temporary steps that can help you navigate a somewhat difficult transition period.
The first suggestion is to restrict meals to a particular area of your house. These areas should not be within arms length of food and you should avoid eating in your bedroom or bathroom. In doing this, you can decrease the number of rooms you associate with eating and also diminish the ease of access to additional food during meals, thereby decreasing the chances of a binge.
The second suggestion is to concentrate while eating. Binge episodes are often characterized by dissociation and a sense that things are simply happening beyond your control. By using focused concentration - mindfulness skills for example - you can thus keep your focus on the moment and on the neutral stimulus of food itself rather than becoming overly concerned with momentary emotions or past upsetting incidents.
The third suggestion is to only have a preplanned amount of food available. By doing so, you will not have to exert significant restraint in the moment in order to resist excessive eating.
When you feel the urge to binge, you should note this in your current food monitoring worksheet. At this point, take out your list of alternative behaviors and choose one that is possible given your current circumstances. If none of the options seems likely to work, try one anyway. If that does not work, try another. Keep going down your list, trying each one for at least several minutes. The idea here is not that any of these particular activities is magical and heals your urge to binge, but rather that distracting yourself breaks up rumination and allows your emotions to return to a baseline level less likely to inspire a binge. As such, the simple act of doing something can be beneficial, much as we outlined in a prior description of behavioral activation in CBT for depression.
Step 3 thus trains you to do two things: identify early on when you begin to feel the urge to binge eat and develop skills for handling such urges in alternative, healthy ways.
Here, Fairburn describes six things to do when faced with stress in order to effectively manage the situation (Items found on page 178 of Overcoming Binge Eating):
- Identify the problem as early as possible
- Specify the problem accurately
- Consider as many solutions as possible
- Thank through the implications of each solution
- Choose the best solution or combination of solutions
- Act on the solution
The first form of dieting is attempting not to eat for extended periods of time. As mentioned above, skipping meals primes your body to binge, so this is not a reasonable long term strategy as it results in a net gain in terms of caloric intake.
The second form of dieting is attempting to restrict caloric intake. Diets of this sort have, in large part, been shown to be ineffective. Descriptions of those with positive empirical evidence is beyond the scope of this article, but they are few and far between. By keeping a strict calorie limit, individuals set themselves up to binge in two ways. First, if the calorie limit is too low, they prime themselves just as they do in the first form of dieting. Additionally, if they have a strict limit and violate it even a little, the response is often to decide that all is lost and, subsequently, a binge becomes likely.
The third form of dieting is avoiding certain types of food. Individuals who binge eat often report having a "banned foods" list. Sometimes these lists only include unhealthy items, but this is not universally the case. Banned food lists often result in subjective binges, which in turn can result in actual binge eating episodes. For instance, an individual may consider cookies to be a banned food. If she then takes a bite of a cookie, she might consider this a binge, even though she only had one bite. This is a subjective binge. At this point, she might decide that she has violated her rules and that she obviously has no control over what she does and subsequently binge eat. This, quite obviously, is not a healthy pattern.
In order to address this third form of dieting, in vivo exposure is often highly useful. In vivo exposure is not typically recommended without the initial help of a therapist, as it can be quite distressing. In the context of therapy, in vivo exposure involves bringing specified items from your banned food list into session. During the session, you and your therapist will consume a preplanned amount of that food while monitoring your anxiety level and challenging your beliefs about what it means to eat that food and what will happen as a result of eating it. Importantly, the exposure session does not end until all anxiety is alleviated, thereby allowing you to learn that the anxiety caused by ingesting banned foods is temporary and that the feared consequences are unrealistic and exaggerated. The goal is to help you learn how to eat moderate amounts of all foods and to protect against the idea that even a bite of particular foods constitutes a binge.
This summary of Fairburn's work is not meant to be a source for therapy, but rather a description of the general structure of treatment. If you are interested in learning more about this approach, using it to combat your own struggles with binge eating, or integrating it into your therapeutic practice, I strongly urge you to acquire the books themselves, which are listed below and available through our online store.