466 CHAPTER 10
P: My friend is prettier than I am, so that means that people like her more
and like me less, and she’s thinner. So I guess the underlying problem
thought is that people don’t like me because I’m fat and ugly. [... ]
T: What is the evidence to support the view that people don’t like you be-
cause you are fat and ugly?
P: Well, I am fat and ugly.
T: I think you know that is subjective, not objective. [... ]
P: More people talked to her than me.
(Agras & Apple, 1997, pp. 95–96; Agras & Apple, 2008, pp. 107–108)
Notice the underlying circularity in the patient’s reasoning: Because the patient be-
lieves that more people talked to her friend than talked to her, that is “proof” that it
was because her friend is thinner and prettier.Effi cacy of CBT for Treating Eating Disorders
Most people with eating disorders who improve signifi cantly with CBT do so within
the fi rst month of treatment (Agras, Crow, et al., 2000). Others may improve some-
what but may stop treatment because they feel that it isn’t helping them. Although
CBT helps decrease their bingeing, purging, and dieting behaviors, up to 50% of
patients retain some symptoms after the treatment ends (Lundgren, Danoff-Burg, &
Anderson, 2004). One study of 48 patients who completely abstained from binge-
ing and purging after CBT found that 44% had relapsed 4 months later (Halmi
et al., 2002). Those who relapsed had more eating rituals, were more preoccupied
with food-related thoughts, and were less motivated to change their behavior.
Why does CBT not help everyone with an eating disorder? There’s no simple
answer. Some studies that examined the presence of comorbid disorders—
particularly personality disorders—found that people with comorbid disorders tend
to respond less well than those with only the eating disorder (Bandini et al., 2006;
Bruce & Steiger, 2005). Although CBT may be the treatment of choice and helps
many people with eating disorders, it clearly isn’t a panacea.Targeting Social Factors
Given the important role that social factors play in contributing to eating disorders,
it is not surprising that various effective treatments directly target these factors.
Treatments that target social factors include interpersonal therapy, family therapy,
group-based inpatient treatment programs, and prevention programs.Interpersonal Therapy
Interpersonal therapy (IPT) has been applied to eating disorders, in the form of man-
ual-based treatment consisting of 4 to 6 months of weekly therapy (Fairburn, 1998).
In any form of IPT, the focus is on problems in relationships that contribute to the
onset, maintenance, and relapse of the disorder (Frank & Spanier, 1995; Klerman &
Weissman, 1993). IPT thus is designed to improve current relationships and social
functioning in general. Although IPT was originally developed to treat depression,
the idea behind IPT for eating disorders is that as problems with relationships re-
solve, symptoms decrease, even though the symptoms are not addressed directly by
the treatment (Swartz, 1999; Tantleff-Dunn, Gokee-LaRose, & Peterson, 2004).
How does IPT work? The hypothesized mechanism is as follows: (1) IPT re-
duces longstanding interpersonal problems; and (2) the resulting improvement of
relationships makes people feel hopeful and empowered, and increases their self-
esteem. These changes have four effects: First, they lead people to change other
aspects of their lives, such as disordered eating; second, they lead to less concern
about appearance and weight, and therefore less dieting and bingeing (Fairburn,
1997); third, as relationships improve, people have more social contact and hence
less time to engage in disordered eating behaviors; and fi nally, with less interper-
sonal stress, people don’t need to expend as much effort on coping and have less
need for bingeing and purging to manage their (less frequent) negative feelings.P SN