Cognitive Reframing And Restructuring

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Cognitive restructuring is described in detail by the Spiegels in their book, Trance and Treatment (1978), and also by cognitive-behavioral therapists such as Meichen-baum (1977) and Kroger and Fezler (1976). In essence, the patient is taught a new way of looking at an old problem and finding new, creative solutions in situations where the patient was cognitively 'chasing his own tail,' and feeling stuck with no way out. The patient with an eating disorder is first guided into a state of self-hypnotic trance, in which the patient is highly receptive to new ideas and suggestions. Under hypnosis, the patient is asked to signify if willing to fully cooperate in this process of therapy, with the aid of ideomotor signalling. Providing the signal is in the affirmative, the therapist may proceed as follows:

As you are sitting in this chair, in this special state of extra-receptivity and self-hypnotic trance, you realize that your subconscious mind has now become your ally, and together you are making the commitment to develop a new relationship between yourself and your body. In this relationship you, in fact, vow to respect and protect your body for the rest of your life. You are learning to develop a new view of your body as a helpless little creature that is totally dependent on you to be taken care of. In fact, your body is like a precious plant through which you can experience life itself, and to the extent that you want to live your life to the fullest, you owe your body this respect and protection. You also become aware that if not for you, for your body, binge eating and purging are, in fact, a poison. (For bulimic patients. For anorexic patients, modify this statement to say: 'For your body, if not for you, self-starvation is, in fact, a poison'). You realize that you cannot live without your body. Your body is this precious plant through which you experience life itself, so you need your body to live, and to the extent that you want to live your life to the fullest, you owe your body this respect and protection. Do you agree? [ Waiting for an ideomotor signal of confirmation.] Now, these are the three principles which reaffirm your commitment to respect and protect your body for the rest of your life. This new commitment is going to be locked in from now on, and forever with the thought to binge, to purge, or to self-starve. Anytime the thought for bingeing, purging, or self-starvation arises it will be locked in with the new commitment to respect and protect your body. Since you and your subconscious have committed to support, strengthen, and empower the commitment to respect and protect your body, the destructive thoughts for bingeing, purging, or self-starvation are going to become weaker, and eventually dissipate away, as if they were never there. Are you willing to reaffirm your commitment and your vow to respect and protect your body for the rest of your life? [Wait for the affirmative response through ideomotor signalling, or in words. If the answer is yes, proceed in the following way]: Now, repeat after me the following statements, reaffirming your commitment as a whole person on a conscious and subconscious level: (a) for my body, if not for me, bingeing, purging, or self-starvation are, in fact, a poison [ patient verbally repeats statement]; (b) I need my body to live [patient verbally repeats statement]; (c) To the extent that I want to live my life to the fullest, I owe my body this respect and protection [ patient verbally repeats statement]. Now that you have reaffirmed your commitment and vow to respect and protect your body for the rest of your life, I suggest you do this exercise once every two hours ...

In fact, you are going to regain a sense of mastery and control in your life as it relates to activities on your job, your plans for the future, the learning of new things, and in your relationships with other people. Now, I would like you to take a moment or so to visualize yourself as fully healed and recovered in the future. Notice the sense of joy and accomplishment as you look at your life and your healthy body. You continue your self-hypnotic exercises which you are going to do safely and comfortably on a regular basis

This hypnotic session is followed by a discussion with the patient whereby the patient learns to avoid self-entrapment, using the principle of 'don't think about a purple elephant.' The patient is asked to engage in a thought exercise whereby she is asked not to think about a purple elephant. Most patients smile and report immediately that they picture a nice, big, purple elephant. The patient is then told:

you see, free people don't like to be told don't. Your subconscious mind does not incorporate the word 'don't', and only hears, 'think about a purple elephant,' and then complies appropriately. The same thing happens when you say to yourself, 'don't binge', or 'don't purge.' You are, in fact, giving yourself the suggestion to binge and to purge, and thus entrapping yourself in doing exactly what you're wishing to avoid. In this new approach any time you experience the thought to binge, purge, or use self-starvation this is your signal to engage in a state of self-hypnosis, and reaffirm your commitment and your vow to respect and protect your body for the rest of your life. So, now you focus on your vow to respect and protect your body for the rest of your life, and on your future reality of yourself living as a healthy, recovered individual.

In a patient with anorexia nervosa an additional method of cognitive reframing is set up whereby we talk about 'gaining strength' instead of 'gaining weight.' The patient is instructed that each strength unit is equal to one pound of body weight. Since most patients with anorexia nervosa who are extremely emaciated get into treatment feeling tired and physically weak, these presenting symptoms are capitalized on by asking them, under hypnosis, whether they would be willing to regain their strength. Most patients respond positively to such a suggestion, and this method uses the principle of 'meet the patient where the patient is at.' Meeting the patient at her level means devising a treatment plan that will be accepted by the patient with minimal resistance. The patient with anorexia nervosa, who suffers from a low body weight, tiredness and physical weakness, engages more readily and is more cooperative in activities focused on supplying her body with healthy nutrition in wholesome meals so she can regain her strength.

In this method, the patient is guided into a state of self-hypnotic trance relaxation and calmness induced in a nature scene of the patient's choice. This is followed by the use of symbolic guided imagery intended to introduce a variety of natural images communicating changes of maturation, differentiation, integration, growth, self-mastery, control, and freedom of choice (Baker & Nash, 1987). I like to use natural images of transformation such as the metamorphoses of a caterpillar through a cocoon into a mature, well-differentiated butterfly. The butterfly is well differentiated sexually and can fly freely from flower to flower and choose its own mate, while the caterpillar is asexual, cannot fly (is immature) and is limited with its choices of food and resources. This has a special value for the immature adolescent patient who struggles with conflicts around gender identity. Another useful image is 'The Red Balloon Technique' (Walch, 1976) which was adapted by Hammond (1987) as an effective adjunct in helping patients to alleviate dysfunctional guilt. I also use images for gaining a sense of control and mastery by asking the patient to visualize herself driving a car, holding the steering wheel in both hands, turning to the right, or left whenever she wishes to do so, changing the speed of her travel in the car, moving forward, or reversing, and using the brakes and other control instruments in the car, based on her need and travel plans. All these are suggested in association with a sense of pleasure and self-mastery.

Another image is one of the patient remodelling and redecorating her room, the room being analogous to the patient's body. First, one imagines living in an old room where the patient feels dissatisfied, then imagery is used in which the patient visualizes the remodelling and redecorating of her room to meet her needs. Emphasis is put on the patient's choice of colours, materials, furniture, drapes, pictures, and so on. Another effective image is that of the patient adopting a puppy or kitten, perhaps a sick one from the animal shelter of the local community. Then, instruct the patient to visualize the kitten or puppy nursed into full health through the patient's commitment and dedication. The sick pet is naturally a metaphor of the patient's unhealthy body, to which they make a commitment to heal and nurse back to full physical health.

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