I wanted to write about problem reduction in CBT. While I was thinking about how to approach it, I got distracted by something more interesting and important. So then I had all the ideas about problem reduction and all the more interesting and important ideas swirling around in my head at the same time. Finally, all the swirling ideas started to settle and organize themselves…and here’s the result.
In her Marine Snow blog, Lola publishes a piece by her Dad: Anorexia: How To Become Special Again This is interesting and important — here are my thoughts about it.
I have never had an eating disorder (ED) myself, but I am acquainted with some people who have. This gives me and Lola’s Dad somewhat similar perspectives.
And curiously, Dad’s approach to writing is quite unlike Lola’s. His writing seems to aim at being logical and persuasive, somewhat like mine, while Lola’s is analytical and personal in a way that makes me hold my breath at times while I try to take it in. (I don’t know how she does that.) So again Dad and I seem to have something in common in our styles of writing.
But that’s where the similarity ends. I don’t agree with much that Dad writes.
…specialness arrives when you become noticed for bodily changes…
This is Stage 1. You could call it the pre-anorexic stage… this is where it often starts.
I think this is balderdash. Huge numbers of normal people make deliberate changes to the way they look in huge numbers of ways, many of them by controlling what they eat and their activities. If they are successful, other people admire them for it. This is not “Stage 1” of any mental illness. It’s normal.
Normality and mental illness are not a continuum, not a lifestyle choice. There is a step change, a quantum leap (which is to say a very tiny, significant, and reversible alteration), between normal and mental illness. That’s why being a bit sad, or even very sad, is not stage 1 of a depressive illness, looking in mirrors a lot is not stage 1 of narcissistic personality disorder, and feeling tired is not stage 1 of death.
What psychotherapists do, if they’re any good, is trace the illness back to the step change, the cognitive distortion (in CBT jargon), and try to fix the problem there. If that’s successful, the illness basically resolves itself.
…take one step too far, take the weight loss to excess, and the admiration turns to horror or disgust. … This, my friends, is Stage 2. This is where the long-term anorexics hang out.
…to continue to feel special, they must be seen to be special by their peers – other anorexics. Unfortunately they have to be more anorexic than the others to gain that respect. … And first prize, of course, can only be awarded posthumously – to win it you have to die.
I think this is codswallop. ED as a competitive sport? Suicide as the first prize? The people I have known who have EDs have felt tormented from within, not driven by external competition. The people I have known who wanted to die have felt defeated, not victorious.
Stage 3 refers to recovering anorexics. … As the recovering anorexic learns that what was thought to be self-control was an illusion, so the wider audience sees the emergence of true self-control. … those that succeed will be the ones that are seen to be really “special”. Now get this: This is a special kind of specialness.
I think this is bullshit. Although Dad’s italics there give it away, the reason is subtle.
What’s all this really about? It’s certainly not about eating disorders in themselves. It’s about specialness. And specialness, not eating or body image, is the point of departure from normality in this thinking, the cognitive distortion, the step change that underlies the illness.
Normal people don’t feel special. They mostly feel ordinary, if they think about it at all. They might feel a bit special at times, and at other times they might feel a bit like they merge into the background. The thing is, specialness is not an issue for normal people.
So suppose a person is mentally ill, and suppose the origin of the illness, the step change, is a feeling that being special is vital for existence — a craving for specialness. Now this person makes a long and hellish journey through EDs, and finally arrives at Dad’s stage 3, a special kind of specialness. Is this an end point? No. It’s just the same thing with knobs on. It’s confirmation of the illness itself. It’s a loopback to the very thing that caused the problem in the first place.
Sorry, Lola’s Dad, I think I can see where you’re coming from with this, but I don’t think you saw where it was going.
Let me point out, by the way, just in case it needs saying, that this is not a diagnosis of anyone. This is a rant in an anonymous blog. The difference is that this rant has only the vaguest connection with any real person, while a diagnosis, or formulation to be more precise, is a the result of very close collaboration between a patient and a therapist. There’s no collaboration going on here, just me ranting in my lunch hour.
So back to problem reduction in CBT. That’s what it is — that stuff I wrote above. It’s when you as a therapist let everything you know about your patient and everything you know about life swirl around in your head until it starts to settle, and as it settles you glimpse what’s at the centre. What’s at the centre is the step change, the cognitive distortion that caused the illness.
If you’re not doing that work, that swirling and settling and glimpsing, then you’re not doing psychotherapy, because you are not distilling all the things you know about your patient into a meaningful whole. Instead you are constantly being distracted by having to deal with each thing separately.
There are plenty of people who try do do therapy while avoiding that work. They administer tests and arrive at diagnoses. They list symptoms and advise on coping strategies. They may be sympathetic to distress and encouraging about recovery. They may do all these things well, but it’s not psychotherapy.
Aaron T. Beck wrote about it like this, referring to a woman with depression in this case. The passage is from Chapter 1 of Cognitive Therapy and the Emotional Disorders:
In order to understand…we need to get inside her conceptual system and see the world through her eyes. We cannot be bound by preconceptions that are applicable to people who are not depressed. Once we are familiar with the perspectives of the depressed patient, her behavior begins to make sense. Through a process of empathy and identification with the patient, we can understand the meanings she attaches to her experiences. We can then offer explanations that are plausible—given her frame of reference.